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Golden BP, Okrainec K. Lost in Translation: How Do We Embed Evidence-Based Communication Strategies into Care Transitions? Jt Comm J Qual Patient Saf 2023; 49:65-67. [PMID: 36566127 DOI: 10.1016/j.jcjq.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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2
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Keniston A, McBeth L, Pell J, Bowden K, Metzger A, Nordhagen J, Anthony A, Rice J, Burden M. The Effectiveness of a Multidisciplinary Electronic Discharge Readiness Tool: Prospective, Single-Center, Pre-Post Study. JMIR Hum Factors 2021; 8:e27568. [PMID: 34747702 PMCID: PMC8663627 DOI: 10.2196/27568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/23/2021] [Accepted: 06/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background In the face of hospital capacity strain, hospitals have developed multifaceted plans to try to improve patient flow. Many of these initiatives have focused on the timing of discharges and on lowering lengths of stay, and they have met with variable success. We deployed a novel tool in the electronic health record to enhance discharge communication. Objective The aim of this study is to evaluate the effectiveness of a discharge communication tool. Methods This was a prospective, single-center, pre-post study. Hospitalist physicians and advanced practice providers (APPs) used the Discharge Today Tool to update patient discharge readiness every morning and at any time the patient status changed throughout the day. Primary outcomes were tool use, time of day the clinician entered the discharge order, time of day the patient left the hospital, and hospital length of stay. We used linear mixed modeling and generalized linear mixed modeling, with team and discharging provider included in all the models to account for patients cared for by the same team and the same provider. Results During the pilot implementation period from March 5, 2019, to July 31, 2019, a total of 4707 patients were discharged (compared with 4558 patients discharged during the preimplementation period). A total of 352 clinical staff had used the tool, and 84.85% (3994/4707) of the patients during the pilot period had a discharge status assigned at least once. In a survey, most respondents reported that the tool was helpful (32/34, 94% of clinical staff) and either saved time or did not add additional time to their workflow (21/24, 88% of providers, and 34/34, 100% of clinical staff). Although improvements were not observed in either unadjusted or adjusted analyses, after including starting morning census per team as an effect modifier, there was a reduction in the time of day the discharge order was entered into the electronic health record by the discharging physician and in the time of day the patient left the hospital (decrease of 2.9 minutes per additional patient, P=.07, and 3 minutes per additional patient, P=.07, respectively). As an effect modifier, for teams that included an APP, there was a significant reduction in the time of day the patient left the hospital beyond the reduction seen for teams without an APP (decrease of 19.1 minutes per patient, P=.04). Finally, in the adjusted analysis, hospital length of stay decreased by an average of 3.7% (P=.06). Conclusions The Discharge Today tool allows for real time documentation and sharing of discharge status. Our results suggest an overall positive response by care team members and that the tool may be useful for improving discharge time and length of stay if a team is staffed with an APP or in higher-census situations.
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Affiliation(s)
- Angela Keniston
- Anschutz Medical Campus, Division of Hospital Medicine, University of Colorado, Aurora, CO, United States
| | - Lauren McBeth
- Anschutz Medical Campus, Division of Hospital Medicine, University of Colorado, Aurora, CO, United States
| | - Jonathan Pell
- Anschutz Medical Campus, Division of Hospital Medicine, University of Colorado, Aurora, CO, United States
| | - Kasey Bowden
- Anschutz Medical Campus, Division of Hospital Medicine, University of Colorado, Aurora, CO, United States
| | - Anna Metzger
- Colorado School of Public Health, University of Colorado, Aurora, CO, United States
| | | | | | - John Rice
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, United States
| | - Marisha Burden
- Anschutz Medical Campus, Division of Hospital Medicine, University of Colorado, Aurora, CO, United States
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Savoy A, Saleem JJ, Barker BC, Patel H, Kara A. Mobile technology for hospitalists: Clinician perspectives and unmet needs from a workflow analysis. JMIR Hum Factors 2021; 9:e28783. [PMID: 34643530 PMCID: PMC8767475 DOI: 10.2196/28783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/01/2021] [Accepted: 10/10/2021] [Indexed: 11/15/2022] Open
Abstract
Background The hospitalist workday is cognitively demanding and dominated by activities away from patients’ bedsides. Although mobile technologies are offered as solutions, clinicians report lower expectations of mobile technology after actual use. Objective The purpose of this study is to better understand opportunities for integrating mobile technology and apps into hospitalists’ workflows. We aim to identify difficult tasks and contextual factors that introduce inefficiencies and characterize hospitalists’ perspectives on mobile technology and apps. Methods We conducted a workflow analysis based on semistructured interviews. At a Midwestern US medical center, we recruited physicians and nurse practitioners from hospitalist and inpatient teaching teams and internal medicine residents. Interviews focused on tasks perceived as frequent, redundant, and difficult. Additionally, participants were asked to describe opportunities for mobile technology interventions. We analyzed contributing factors, impacted workflows, and mobile app ideas. Results Over 3 months, we interviewed 12 hospitalists. Participants collectively identified chart reviews, orders, and documentation as the most frequent, redundant, and difficult tasks. Based on those tasks, the intake, discharge, and rounding workflows were characterized as difficult and inefficient. The difficulty was associated with a lack of access to electronic health records at the bedside. Contributing factors for inefficiencies were poor usability and inconsistent availability of health information technology combined with organizational policies. Participants thought mobile apps designed to improve team communications would be most beneficial. Based on our analysis, mobile apps focused on data entry and presentation supporting specific tasks should also be prioritized. Conclusions Based on our results, there are prioritized opportunities for mobile technology to decrease difficulty and increase the efficiency of hospitalists’ workflows. Mobile technology and task-specific mobile apps with enhanced usability could decrease overreliance on hospitalists’ memory and fragmentation of clinical tasks across locations. This study informs the design and implementation processes of future health information technologies to improve continuity in hospital-based medicine.
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Affiliation(s)
- April Savoy
- Center for Health Information and Communication, Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Indianapolis, US.,Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indianapolis, Indianapolis, US.,Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, US
| | - Jason J Saleem
- Department of Industrial Engineering, J.B. Speed School of Engineering, University of Louisville, Louisville, US
| | - Barry C Barker
- Center for Health Information and Communication, Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Indianapolis, US
| | - Himalaya Patel
- Center for Health Information and Communication, Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Indianapolis, US
| | - Areeba Kara
- Indiana University Health Physicians, Indianapolis, US.,Indiana University School of Medicine, Indianapolis, US
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4
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Fralick M, Kaw N, Wang M, Mamdani M, Mourad O. Analyzing supply and demand on a general internal medicine ward: a cross-sectional study. CMAJ Open 2021; 9:E1021-E1025. [PMID: 34785532 PMCID: PMC8598238 DOI: 10.9778/cmajo.20200252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The capacity of general internal medicine (GIM) clinical teaching units has been strained by decreasing resident supply and increasing patient demand. The objective of our study was to compare the number of residents (supply) with the volume and duration of patient care activities (demand) to identify inefficiency. METHODS Using the most recently available data from an academic teaching hospital in Toronto, Ontario, we identified each occurrence of a set of patient care activities that took place on the clinical teaching unit from 2015 to 2019. We completed a descriptive analysis of the frequencies of these activities and how the frequencies varied by hour, day, week, month and year. Patient care activities included admissions, rounds, responding to pages, meeting with patients and their families, patient transfers, discharges and responding to cardiac arrests. The estimated time to complete each task was based on the available data in our electronic medical record system and interviews with GIM physicians and trainees. To calculate resident utilization, the person-hours of patient care tasks was divided by the person-hours of resident supply. Resident utilization was computed for 3 scenarios corresponding to varying levels of resident absenteeism. RESULTS During the study period, there were 14 581 consultations to GIM from the emergency department. Patient volumes tended to be highest during January and lowest during May and June, and highest on Monday morning and lowest on Friday night. Daily admissions to hospital from the emergency department were higher on weekdays than on weekends, and hourly admissions peaked at 8 am and between 3 pm and 1 am. Weekday resident utilization was generally highest between 8 am and 2 pm, and lowest between 1 am and 8 am. In a scenario in which all residents were present apart from those who were post-call, resident utilization generally never exceeded 100%; in scenarios in which at least 1 resident was absent owing to illness or vacation, it was common for resident utilization to approach or exceed 100%, particularly during daytime working hours. INTERPRETATION Analyzing supply and demand on a GIM ward has allowed us to identify periods when supply and demand are not aligned and to demonstrate empirically the vulnerability of current staffing models. These data have the potential to inform and optimize scheduling on an internal medicine ward.
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Affiliation(s)
- Michael Fralick
- Sinai Health System and the Department of Medicine (Fralick), University of Toronto; Li Ka Shing Centre for Healthcare Analytics Research and Training (Fralick, Kaw, Wang, Mamdani), St. Michael's Hospital, Toronto, Ont.; Operations Research Center (Kaw), Massachusetts Institute of Technology, Cambridge, Mass.; Unity Health (Mourad), Department of Medicine, University of Toronto, Toronto, Ont.
| | - Neal Kaw
- Sinai Health System and the Department of Medicine (Fralick), University of Toronto; Li Ka Shing Centre for Healthcare Analytics Research and Training (Fralick, Kaw, Wang, Mamdani), St. Michael's Hospital, Toronto, Ont.; Operations Research Center (Kaw), Massachusetts Institute of Technology, Cambridge, Mass.; Unity Health (Mourad), Department of Medicine, University of Toronto, Toronto, Ont
| | - Mingkun Wang
- Sinai Health System and the Department of Medicine (Fralick), University of Toronto; Li Ka Shing Centre for Healthcare Analytics Research and Training (Fralick, Kaw, Wang, Mamdani), St. Michael's Hospital, Toronto, Ont.; Operations Research Center (Kaw), Massachusetts Institute of Technology, Cambridge, Mass.; Unity Health (Mourad), Department of Medicine, University of Toronto, Toronto, Ont
| | - Muhammad Mamdani
- Sinai Health System and the Department of Medicine (Fralick), University of Toronto; Li Ka Shing Centre for Healthcare Analytics Research and Training (Fralick, Kaw, Wang, Mamdani), St. Michael's Hospital, Toronto, Ont.; Operations Research Center (Kaw), Massachusetts Institute of Technology, Cambridge, Mass.; Unity Health (Mourad), Department of Medicine, University of Toronto, Toronto, Ont
| | - Ophyr Mourad
- Sinai Health System and the Department of Medicine (Fralick), University of Toronto; Li Ka Shing Centre for Healthcare Analytics Research and Training (Fralick, Kaw, Wang, Mamdani), St. Michael's Hospital, Toronto, Ont.; Operations Research Center (Kaw), Massachusetts Institute of Technology, Cambridge, Mass.; Unity Health (Mourad), Department of Medicine, University of Toronto, Toronto, Ont
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Keniston A, McBeth L, Pell J, Bowden K, Ball S, Stoebner K, Scherzberg E, Moore SL, Nordhagen J, Anthony A, Burden M. Development and Implementation of a Multidisciplinary Electronic Discharge Readiness Tool: User-Centered Design Approach. JMIR Hum Factors 2021; 8:e24038. [PMID: 33890860 PMCID: PMC8105757 DOI: 10.2196/24038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/16/2021] [Accepted: 03/29/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Typical solutions for improving discharge planning often rely on one-way communication mechanisms, static data entry into the electronic health record (EHR), or in-person meetings. Lack of timely and effective communication can adversely affect patients and their care teams. OBJECTIVE Applying robust user-centered design strategies, we aimed to design an innovative EHR-based discharge readiness communication tool (the Discharge Today tool) to enable care teams to communicate any barriers to discharge, the status of patient discharge readiness, and patient discharge needs in real time across hospital settings. METHODS We employed multiple user-centered design strategies, including exploration of the current state for documenting discharge readiness and directing discharge planning, iterative low-fidelity prototypes, multidisciplinary stakeholder meetings, a brainwriting premortem exercise, and preproduction user testing. We iteratively collected feedback from users via meetings and surveys. RESULTS We conducted 28 meetings with 20 different stakeholder groups. From these stakeholder meetings, we developed 14 low-fidelity prototypes prior to deploying the Discharge Today tool for our pilot study. During the pilot study, stakeholders requested 46 modifications, of which 25 (54%) were successfully executed. We found that most providers who responded to the survey reported that the tool either saved time or did not change the amount of time required to complete their discharge workflow (21/24, 88%). Responses to open-ended questions offered both positive feedback and opportunities for improvement in the domains of efficiency, integration into workflow, avoidance of redundancies, expedited communication, and patient-centeredness. CONCLUSIONS Survey data suggest that this electronic discharge readiness tool has been successfully adopted by providers and clinical staff. Frequent stakeholder engagement and iterative user-centered design were critical to the successful implementation of this tool.
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Affiliation(s)
- Angela Keniston
- Division of Hospital Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, United States
| | - Lauren McBeth
- Division of Hospital Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, United States
| | - Jonathan Pell
- Division of Hospital Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, United States
| | - Kasey Bowden
- Division of Hospital Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, United States
| | | | | | | | - Susan L Moore
- Colorado School of Public Health, University of Colorado, Aurora, CO, United States
| | | | | | - Marisha Burden
- Division of Hospital Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, United States
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Hoonakker PLT, Wooldridge AR, Hose BZ, Carayon P, Eithun B, Brazelton TB, Kohler JE, Ross JC, Rusy DA, Dean SM, Kelly MM, Gurses AP. Information flow during pediatric trauma care transitions: things falling through the cracks. Intern Emerg Med 2019; 14:797-805. [PMID: 31140061 PMCID: PMC6692560 DOI: 10.1007/s11739-019-02110-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 05/15/2019] [Indexed: 10/26/2022]
Abstract
Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Every year, nearly 10 million children are evaluated in emergency departments (EDs) for traumatic injuries, resulting in 250,000 hospital admissions and 10,000 deaths. Pediatric trauma care in hospitals is distributed across time and space, and particularly complex with involvement of large and fluid care teams. Several clinical teams (including emergency medicine, surgery, anesthesiology, and pediatric critical care) converge to help support trauma care in the ED; this co-location in the ED can help to support communication, coordination and cooperation of team members. The most severe trauma cases often need surgery in the operating room (OR) and are admitted to the pediatric intensive care unit (PICU). These care transitions in pediatric trauma can result in loss of information or transfer of incorrect information, which can negatively affect the care a child will receive. In this study, we interviewed 18 clinicians about communication and coordination during pediatric trauma care transitions between the ED, OR and PICU. After the interview was completed, we surveyed them about patient safety during these transitions. Results of our study show that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, important patient care information is often lost when transitioning patients between units. To safely manage the transition of this fragile and complex population, we need to find ways to better manage the information flow during these transitions by, for instance, providing technological support to ensure shared mental models.
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Affiliation(s)
- Peter Leonard Titus Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 3124 Engineering Centers Building, 1550 Engineering Drive, Madison, WI, 53706, USA.
| | - Abigail Rayburn Wooldridge
- Department of Industrial & Enterprise Systems Engineering, University of Illinois at Urbana-Champaign, 209A Transportation Building, 104 South Mathews Avenue, Urbana, IL, 61801, USA
| | - Bat-Zion Hose
- Center for Quality and Productivity Improvement, Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 3139 Engineering Centers Building, 1550 Engineering Drive, Madison, WI, 53706, USA
| | - Pascale Carayon
- Center for Quality and Productivity Improvement, Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 3139 Engineering Centers Building, 1550 Engineering Drive, Madison, WI, 53706, USA
| | - Ben Eithun
- American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, 1675 Highland Avenue, Madison, WI, 53792, USA
| | - Thomas Berry Brazelton
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Jonathan Emerson Kohler
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Joshua Chud Ross
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Deborah Ann Rusy
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Shannon Mason Dean
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Michelle Merwood Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Ayse Pinar Gurses
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, 750 East Pratt Street, 15th Floor, Baltimore, MD, 21202, USA
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7
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Okrainec K, Hahn-Goldberg S, Abrams H, Bell CM, Soong C, Hart M, Shea B, Schmidt S, Troup A, Jeffs L. Patients' and caregivers' perspectives on factors that influence understanding of and adherence to hospital discharge instructions: a qualitative study. CMAJ Open 2019; 7:E478-E483. [PMID: 31320331 PMCID: PMC6639098 DOI: 10.9778/cmajo.20180208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many patients have difficulty understanding and adhering to discharge instructions once home from hospital. We assessed patient and family caregiver perspectives on factors that influence understanding of and adherence to discharge instructions. METHODS We conducted a qualitative study using semistructured interviews of participants aged 18 years or more enrolled in a multicentre mixed-methods study who were discharged from 3 acute care hospitals across Ontario with a diagnosis of congestive heart failure, chronic obstructive pulmonary disease or pneumonia. Patients were recruited between March and November 2016. We used directed content analysis to derive themes and subthemes. RESULTS Twenty-seven participants (16 patients and 11 family members) described 5 themes that affected their understanding of and adherence to discharge instructions: 1) the role of caregivers, 2) relationships with inpatient and outpatient health care providers, 3) previous hospital stay, 4) barriers to accessing postdischarge care and 5) system-level processes. Subthemes highlighted the importance participants attributed to who provides the instructions, the development of resilience and advocacy through previous admissions, the benefits of addressing language and physical disability barriers, reviewing instructions in a unhurried manner, and ensuring that written instructions are meaningful and actionable. INTERPRETATION Care transition interventions targeting improved communication are unlikely to improve understanding of and adherence to discharge instructions on their own. A patient-centred framework that promotes positive relationships with a patient's circle of care, reflects previous experiences with discharge, addresses equity barriers, and enhances strategies for patient and caregiver engagement at the time of discharge may optimize understanding and adherence once the patient is home.
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Affiliation(s)
- Karen Okrainec
- Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont.
| | - Shoshana Hahn-Goldberg
- Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont
| | - Howard Abrams
- Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont
| | - Chaim M Bell
- Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont
| | - Christine Soong
- Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont
| | - Michelle Hart
- Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont
| | - Beverley Shea
- Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont
| | - Sandra Schmidt
- Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont
| | - Amy Troup
- Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont
| | - Lianne Jeffs
- Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont
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8
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Gali HE, Baxter SL, Lander L, Huang AE, Millen M, El-Kareh R, Nudleman E, Chao DL, Robbins SL, Heichel CWD, Camp AS, Korn BS, Lee JE, Kikkawa DO, Longhurst CA, Chiang MF, Hribar MR, Ohno-Machado L. Impact of Electronic Health Record Implementation on Ophthalmology Trainee Time Expenditures. JOURNAL OF ACADEMIC OPHTHALMOLOGY 2019; 11:e65-e72. [PMID: 33954272 DOI: 10.1055/s-0039-3401986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Objective Electronic health records (EHRs) are widely adopted, but the time demands of EHR use on ophthalmology trainees are not well understood. This study evaluated ophthalmology trainee time spent on clinical activities in an outpatient clinic undergoing EHR implementation. Design Prospective, manual time-motion observations of ophthalmology trainees in 2018. Participants Eleven ophthalmology residents and fellows observed during 156 patient encounters. Methods Prospective time-motion study of ophthalmology trainees 2 weeks before and 6 weeks after EHR implementation in an academic ophthalmology department. Manual time-motion observations were conducted for 11 ophthalmology trainees in 6 subspecialty clinics during 156 patient encounters. Time spent documenting, examining, and talking with patients were recorded. Factors influencing time requirements were evaluated using linear mixed effects models. Main Outcome Measures Total time spent by ophthalmology residents and fellows per patient, time spent on documentation, examination, and talking with patients. Results Seven ophthalmology residents and four ophthalmology fellows with mean (standard deviation) postgraduate year of 3.7 (1.2) were observed during 156 patient encounters. Using paper charts, mean total time spent on each patient was 11.6 (6.5) minutes, with 5.4 (3.5) minutes spent documenting (48%). After EHR implementation, mean total time spent on each patient was 11.8 (6.9) minutes, with 6.8 (4.7) minutes spent documenting (57%). Total time expenditure per patient did not significantly change after EHR implementation (+0.17 minutes, 95% confidence interval [CI] for difference in means: -2.78, 2.45; p = 0.90). Documentation time did not change significantly after EHR implementation in absolute terms (+1.42 minutes, 95% CI: -3.13, 0.29; p = 0.10), but was significantly greater as a proportion of total time (48% on paper to 57% on EHR; +9%, 95% CI: 2.17, 15.83; p = 0.011). Conclusion Total time spent per patient and absolute time spent on documentation was not significantly different whether ophthalmology trainees used paper charts or the recently implemented EHR. Percentage of total time spent on documentation increased significantly with early EHR use. Evaluating EHR impact on ophthalmology trainees may improve understanding of how trainees learn to use the EHR and may shed light on strategies to address trainee burnout.
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Affiliation(s)
- Helena E Gali
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California.,UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Sally L Baxter
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California.,UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Lina Lander
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Abigail E Huang
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Marlene Millen
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Robert El-Kareh
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Eric Nudleman
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Daniel L Chao
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Shira L Robbins
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Christopher W D Heichel
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Andrew S Camp
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Bobby S Korn
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Jeffrey E Lee
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Don O Kikkawa
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego (UCSD), La Jolla, California
| | - Christopher A Longhurst
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Michael F Chiang
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon.,Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - Michelle R Hribar
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon.,Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - Lucila Ohno-Machado
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California.,Division of Health Services Research and Development, Veterans Administration San Diego Healthcare System, La Jolla, California
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9
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Hahn-Goldberg S, Jeffs L, Troup A, Kubba R, Okrainec K. "We are doing it together"; The integral role of caregivers in a patients' transition home from the medicine unit. PLoS One 2018; 13:e0197831. [PMID: 29795623 PMCID: PMC5993108 DOI: 10.1371/journal.pone.0197831] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022] Open
Abstract
Background An admission to hospital for acute illness can be difficult for patients and lead to high levels of anxiety. Patients are given a lot of information throughout their hospital stay and instructions at discharge to follow when they get home. For complex medical patients, the ability to retain, understand, and adhere to these instructions is a critical marker of a successful transition. This study was undertaken to explore factors impacting the ability of patients to understand and adhere to instructions. Methods A qualitative design of interviews with patients and caregivers was used. Participants were adult patients and caregivers with congestive heart failure, chronic obstructive pulmonary disease, or community-acquired pneumonia being discharged home from three academic acute care hospitals in Ontario, Canada. Semi structured interviews were conducted with participants within one week following their discharge from hospital. Interviews were audiotaped and transcribed. Five independent researchers participated in an iterative process of coding, reviewing, and analyzing the interviews using direct content analysis. Results In total, 27 participants completed qualitative interviews. Analysis revealed the role of the caregiver to be critical in its relation to the ability of patients to understand and adhere to discharge instructions. Within the topic of caregiving, we draw on three areas of insight: The first clarified how caregivers support patients after they are discharged home from the hospital. The second highlighted how caregiver involvement impacts patient understanding and adherence to discharge instructions. The third revealed system factors that influence a caregiver’s involvement when receiving discharge instructions. Conclusion Caregivers play an important role in the transition of a complex medical patient by impacting a patient’s ability to understand and adhere to their discharge instructions. The themes identified in this paper highlight opportunities for healthcare providers and institutions to effectively involve caregivers during transitions from acute care hospitals to home.
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Affiliation(s)
- Shoshana Hahn-Goldberg
- OpenLab, University Health Network, Toronto, Ontario, Canada
- School of Health Policy and Management, Yok University, Toronto, Ontario, Canada
- * E-mail:
| | - Lianne Jeffs
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Amy Troup
- OpenLab, University Health Network, Toronto, Ontario, Canada
| | - Rasha Kubba
- OpenLab, University Health Network, Toronto, Ontario, Canada
| | - Karen Okrainec
- University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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