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Fichadia PA, Virmani M, Shah P, Mahmood R, Kanwar R, Singla A, Jain R. Utilization and efficacy of DotPhrases in the electronic medical record for improving physician documentation. Proc AMIA Symp 2024; 37:692-696. [PMID: 38910803 PMCID: PMC11188808 DOI: 10.1080/08998280.2024.2352993] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/03/2024] [Indexed: 06/25/2024] Open
Abstract
Clinical documentation of patient visits has changed over the last 20 years, with the increasing use of electronic records causing a seismic shift in how notes are taken. Electronic note-taking aims at reducing the time taken to document a visit, and the introduction of dot phrases, or DotPhrases, in electronic medical records is a step toward reducing the time required to update patients' charts, which might allow doctors to spend more time with their patients. DotPhrases, abbreviated phrases used in the electronic medical record, help in the simplification of note-taking and the standardization of notes. They also allow for a more comprehensive note from physicians and ensure that no information is undocumented. On the contrary, however, excessive usage of DotPhrases can lead to an excessively long and cumbersome note. This can overwhelm physicians and lead to them missing crucial information that is buried somewhere in the notes. Although there is ample research studying the benefits of DotPhrases, adequate research must also be carried out to understand their shortcomings and disadvantages. This article aims to shed some light on use of DotPhrases and to outline their advantages and disadvantages affecting patient management and care.
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Affiliation(s)
- Palak A. Fichadia
- Department of Medicine, Smt. N.H.L Municipal Medical College, Gujarat, India
| | - Mini Virmani
- Department of Quality Improvement, Penn Medicine Princeton Medical Center, Plainsboro Township, New Jersey, USA
| | - Priyanshi Shah
- Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramsha Mahmood
- Avalon University School of Medicine, Willemstad, Curaçao
| | - Rhea Kanwar
- Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Amishi Singla
- Dallastown Area High School, York, Pennsylvania, USA
| | - Rohit Jain
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Scott IA, Zuccon G. The new paradigm in machine learning - foundation models, large language models and beyond: a primer for physicians. Intern Med J 2024; 54:705-715. [PMID: 38715436 DOI: 10.1111/imj.16393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/26/2024] [Indexed: 05/18/2024]
Abstract
Foundation machine learning models are deep learning models capable of performing many different tasks using different data modalities such as text, audio, images and video. They represent a major shift from traditional task-specific machine learning prediction models. Large language models (LLM), brought to wide public prominence in the form of ChatGPT, are text-based foundational models that have the potential to transform medicine by enabling automation of a range of tasks, including writing discharge summaries, answering patients questions and assisting in clinical decision-making. However, such models are not without risk and can potentially cause harm if their development, evaluation and use are devoid of proper scrutiny. This narrative review describes the different types of LLM, their emerging applications and potential limitations and bias and likely future translation into clinical practice.
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Affiliation(s)
- Ian A Scott
- Centre for Health Services Research, University of Queensland, Woolloongabba, Australia
| | - Guido Zuccon
- School of Electrical Engineering and Computer Sciences, The University of Queensland, St Lucia, Queensland, Australia
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Jabin MSR, Pan D, Nilsson E. Characterizing patient details-related challenges from health information technology-related incident reports from Swedish healthcare. Front Digit Health 2024; 6:1260521. [PMID: 38380372 PMCID: PMC10876894 DOI: 10.3389/fdgth.2024.1260521] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024] Open
Abstract
Introduction Despite many benefits offered by Health Information Technology (HIT) systems, new technology brings new and unforeseen risks to healthcare quality and patient safety if they're not properly planned, designed, implemented, and managed. This study examined health information technology-related (HIT) incidents to identify patient details-related issues, their association with contributing factors, and outcomes. Methods Sources of information comprised retrospectively collected incident reports (n = 95) using two sampling methods, i.e., purposive and snowball sampling. The incident reports were analyzed using both the inductive method (thematic analysis) and the deductive approach using an existing framework, i.e., the International Classification for Patient Safety. Results The studies identified 90 incidents with 120 patient details-related issues-categorized as either information-related (48%) or documentation-related (52%) problems; around two-thirds of the 120 issues were characterized by human factors. Of the total sample, 87 contributing factors were identified, of which "medical device/system" (45%) and "documentation" (20%) were the most common contributing factors. Of 90 incidents, more than half (59%) comprised patient-related outcomes-patient inconvenience (47%) and patient harm (12%) and the remaining 41% (n = 37) included staff or organization-related outcomes. Discussion More than half of the incidents resulted in patient-related outcomes, namely patient inconvenience and patient harm, including disease risks, severe health deterioration, injury, and even patient death. Incidents associated with patient details can cause deleterious effects; therefore, characterizing them should be a routine part of clinical practice to improve the constantly changing healthcare system.
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Affiliation(s)
- Md Shafiqur Rahman Jabin
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
- Faculty of Health Studies, University of Bradford, Bradford, United Kingdom
| | - Ding Pan
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
| | - Evalill Nilsson
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
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Non LR. All aboard the ChatGPT steamroller: Top 10 ways to make artificial intelligence work for healthcare professionals. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e243. [PMID: 38156230 PMCID: PMC10753501 DOI: 10.1017/ash.2023.512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 12/30/2023]
Abstract
Chat Generative Pre-trained Transformer (ChatGPT), the flagship generative artificial intelligence (AI) chatbot by OpenAI, is transforming many things in medicine, from healthcare and research to medical education. It is anticipated to integrate in many aspects of the medical industry, and we should brace for this inevitability and use it to our advantage. Here are proposed ways you can use ChatGPT in medicine with some specific use cases in antimicrobial stewardship and hospital epidemiology.
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Affiliation(s)
- Lemuel R. Non
- Division of Infectious Diseases, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Hassan AG, Elqaffas EO, Elbouridy AM, Shawky MM, El-Fayoumi TA. A Closed-Loop Clinical Audit of Surgical Documentation of Inpatient Records at a Tertiary Level Hospital in Egypt. Cureus 2023; 15:e49862. [PMID: 38170126 PMCID: PMC10759245 DOI: 10.7759/cureus.49862] [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] [Accepted: 12/02/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Optimal record keeping is a very essential component in health care provision especially in the surgical setting. This study aimed to evaluate the quality of surgical records in wards of a surgical department at Alexandria Main University Hospital, Egypt. METHODS We created a systematically designed checklist using standard hospital protocol and universal guidelines presented in the previously validated STAR and CRABEL auditing tools as a basis for Yes/No questions. This checklist was then used to prospectively evaluate the quality of surgical records of patients who underwent surgery in the surgical oncology department from July 2023 to October 2023. Total STAR and section-specific STAR scores were then calculated and compared statistically. RESULTS A total of 80 records were randomly selected and evaluated using the STAR questionnaire. All domains showed improvement compared to the baseline except for the discharge summary which did not change from an already relatively high baseline of 96±0.0. The highest improvements were observed in the anesthetic record and operative record domains which increased from 90.65±4.3 and 86.15±5.347 to 100±0.0 and 95.6±3.365, respectively. CONCLUSION Our study demonstrates that significant improvements in the quality of surgical records can be achieved by simply using preprepared templates, personnel education, and systematic auditing.
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Affiliation(s)
- Ahmed G Hassan
- General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, EGY
| | - Eyad O Elqaffas
- Anesthesiology Department, Alexandria Main University Hospital, Alexandria, EGY
| | - Ahmed M Elbouridy
- Surgical Oncology Department, Alexandria Main University Hospital, Alexandria, EGY
| | - Mazen M Shawky
- Surgical Oncology Department, Alexandria Main University Hospital, Alexandria, EGY
| | - Tarek A El-Fayoumi
- Surgical Oncology Department, Alexandria Main University Hospital, Alexandria, EGY
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Ayer M. Relieving Administrative Burden on Clinical Staff with Streamlined Workflows And Speech-Recognition Software. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:S1-S9. [PMID: 37708052 DOI: 10.12968/bjon.2023.32.sup16b.s4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Affiliation(s)
- Mavis Ayer
- Multiple Sclerosis Lead Nurse, University Hospital Southampton NHS Foundation Trust
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7
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Sharma P, Parasa S. ChatGPT and large language models in gastroenterology. Nat Rev Gastroenterol Hepatol 2023:10.1038/s41575-023-00799-8. [PMID: 37253794 DOI: 10.1038/s41575-023-00799-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Prateek Sharma
- University of Kansas School of Medicine, Kansas City, MO, USA.
- Veteran Affairs Medical Center, Kansas City, MO, USA.
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Harrer S. Attention is not all you need: the complicated case of ethically using large language models in healthcare and medicine. EBioMedicine 2023; 90:104512. [PMID: 36924620 PMCID: PMC10025985 DOI: 10.1016/j.ebiom.2023.104512] [Citation(s) in RCA: 75] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/21/2023] [Accepted: 02/21/2023] [Indexed: 03/17/2023] Open
Abstract
Large Language Models (LLMs) are a key component of generative artificial intelligence (AI) applications for creating new content including text, imagery, audio, code, and videos in response to textual instructions. Without human oversight, guidance and responsible design and operation, such generative AI applications will remain a party trick with substantial potential for creating and spreading misinformation or harmful and inaccurate content at unprecedented scale. However, if positioned and developed responsibly as companions to humans augmenting but not replacing their role in decision making, knowledge retrieval and other cognitive processes, they could evolve into highly efficient, trustworthy, assistive tools for information management. This perspective describes how such tools could transform data management workflows in healthcare and medicine, explains how the underlying technology works, provides an assessment of risks and limitations, and proposes an ethical, technical, and cultural framework for responsible design, development, and deployment. It seeks to incentivise users, developers, providers, and regulators of generative AI that utilises LLMs to collectively prepare for the transformational role this technology could play in evidence-based sectors.
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Affiliation(s)
- Stefan Harrer
- Digital Health Cooperative Research Centre, Melbourne, Australia.
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Bennett S, Newman-Griffis DR, Beach MC, Gross M. Digital Scarlet Letters: Sexually Transmitted Infections in the Electronic Medical Record. Sex Transm Dis 2022; 49:e70-e74. [PMID: 34772894 PMCID: PMC9272463 DOI: 10.1097/olq.0000000000001581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The harms of implicit bias in clinical settings are acknowledged but poorly understood and difficult to overcome. We discuss how structural components of electronic medical record (EMR) user interfaces may contribute to sex and gender-based discrimination against patients via constant, duplicative presentation of stigmatizing sexually transmitted infection (STI) data irrespective of clinical significance. Via comparison with symbolism and representative quotes in Hawthorne's 1850 novel The Scarlet Letter, we propose a metaphor to examine how EMRs function as a platform for moral judgment, which may display an indelible "scarlet letter" for pregnant patients with STI history. We consider whether current depictions of STIs in EMRs are structurally unjust and may contribute to biased treatment by directing attention to violations of hegemonic sex/gender norms regarding sexual behavior and thus triggering moral judgments of maternal fitness. We conclude with recommendations for how to address these challenges to improve ethical stewardship of sensitive sexual/reproductive health data.
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Affiliation(s)
- Sarah Bennett
- Department of Obstetrics and Gynecology, Magee Womens Hospital, University of Pittsburgh Medical Center
| | | | | | - Marielle Gross
- Department of Obstetrics and Gynecology, Magee Womens Hospital, University of Pittsburgh Medical Center
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10
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Alqudah M, Aloqaily M, Rabadi A, Nimer A, Abdel Hafez S, Almomani A, Alkhlaifat NS, Aldurgham A, Al-Momani A, Fraij Z, Aloqaily W, Bani Abedelrahman L, AlShati A, Jabaiti S, Bani Hani A, Abu Abeeleh M. The Value of Auditing Surgical Records in a Tertiary Hospital Setting. Cureus 2022; 14:e21066. [PMID: 35155026 PMCID: PMC8826017 DOI: 10.7759/cureus.21066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 11/05/2022] Open
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de Hoop T, Neumuth T. Evaluating Electronic Health Record Limitations and Time Expenditure in a German Medical Center. Appl Clin Inform 2021; 12:1082-1090. [PMID: 34937102 PMCID: PMC8695058 DOI: 10.1055/s-0041-1739519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES This study set out to obtain a general profile of physician time expenditure and electronic health record (EHR) limitations in a large university medical center in Germany. We also aim to illustrate the merit of a tool allowing for easier capture and prioritization of specific clinical needs at the point of care for which the current study will inform development in subsequent work. METHODS Nineteen physicians across six different departments participated in this study. Direct clinical observations were conducted with 13 out of 19 physicians for a total of 2,205 minutes, and semistructured interviews were conducted with all participants. During observations, time was measured for larger activity categories (searching information, reading information, documenting information, patient interaction, calling, and others). Semistructured interviews focused on perceived limitations, frustrations, and desired improvements regarding the EHR environment. RESULTS Of the observed time, 37.1% was spent interacting with the health records (9.0% searching, 7.7% reading, and 20.5% writing), 28.0% was spent interacting with patients corrected for EHR use (26.9% of time in a patient's presence), 6.8% was spent calling, and 28.1% was spent on other activities. Major themes of discontent were a spread of patient information, high and often repeated documentation burden, poor integration of (new) information into workflow, limits in information exchange, and the impact of such problems on patient interaction. Physicians stated limited means to address such issues at the point of care. CONCLUSION In the study hospital, over one-third of physicians' time was spent interacting with the EHR, environment, with many aspects of used systems far from optimal and no convenient way for physicians to address issues as they occur at the point of care. A tool facilitating easier identification and registration of issues, as they occur, may aid in generating a more complete overview of limitations in the EHR environment.
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Affiliation(s)
- Tom de Hoop
- Innovation Center Computer Assisted Surgery, Institute at the Faculty of Medicine, Leipzig University, Leipzig, Germany,Address for correspondence Tom de Hoop, MD University of Leipzig, Innovation Center Computer Assisted Surgery (ICCAS)Semmelweisstraße 14, 04103 LeipzigGermany
| | - Thomas Neumuth
- Innovation Center Computer Assisted Surgery, Institute at the Faculty of Medicine, Leipzig University, Leipzig, Germany
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12
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Mafrachi B, Al-Ani A, Al Debei A, Elfawair M, Al-Somadi H, Shahin M, Alda'as Y, Ajlouni J, Bani Hani A, Abu Abeeleh M. Improving the Quality of Medical Documentation in Orthopedic Surgical Notes Using the Surgical Tool for Auditing Records (STAR) Score. Cureus 2021; 13:e19193. [PMID: 34873533 PMCID: PMC8635467 DOI: 10.7759/cureus.19193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 11/05/2022] Open
Abstract
Aims Due to the significant value held by medical records in terms of influencing patient care and medico-legal cases, this study aimed to investigate the quality of surgical notes and their improvement through periodic auditing during a six-year period at a major tertiary hospital. Methodology This study retrospectively evaluated surgical records of patients undergoing elective orthopedic surgeries at Jordan University Hospital from 2016 to 2021 using the Surgical Tool for Auditing Records (STAR) validated questionnaire. This questionnaire is composed of six distinct sections aimed to quantify the quality of medical records and demonstrate their associated deficiencies. Pre- and post-audit STAR scores were analyzed using the two independent sample t-test on Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp. Armonk, NY). Results A total of 454 records were randomly selected and evaluated using the STAR questionnaire. There was an overall significant trend of improvement in the quality of records in all evaluated years compared to the 2016 baseline. The most pronounced improvements were in the records of 2021 as compared to the 2016 baseline (97.4 ± 0.7 vs. 94.3 ± 1.6; p:<0.05), in which the Initial Clerking, Subsequent Entries, and Operative Record domains had the most significant magnitude of change. The Consent and Anesthesia domains plateaued over the study's period in terms of overall quality. The most improved STAR domain was the Discharge Summary domain, in which four subsections (follow-up, diagnosis, complications, and medications on discharge) had significant STAR score increases (all; p:<0.05). Conclusion Our study implies that simple measures, including personnel education and training and periodic auditing, are effective measures in increasing the quality of surgical records. High-quality medical records need to be sustained and continuously improved, as they contribute to better health care, promote research, and contribute to economic gains through cost-effective practices.
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Affiliation(s)
- Baraa Mafrachi
- Orthopaedics and Trauma, The University of Jordan, Amman, JOR
| | - Abdallah Al-Ani
- Department of Research, King Hussein Medical Center, Amman, JOR
| | | | | | | | | | - Yazan Alda'as
- School of Medicine, The University of Jordan, Amman, JOR
| | - Jihad Ajlouni
- Orthopaedics, Jordan University Hospital, Amman, JOR
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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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14
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O'Connor S, Zhang M, Honey M, Lee JJ. Digital professionalism on social media: A narrative review of the medical, nursing, and allied health education literature. Int J Med Inform 2021; 153:104514. [PMID: 34139621 DOI: 10.1016/j.ijmedinf.2021.104514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 04/26/2021] [Accepted: 06/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Medical, nursing, and allied health students, and professionals are using online environments such as social media to communicate and share information. However, some have difficulty differentiating between their professional and personal roles and can behave inappropriately online. Better education and training may help prevent these issues from arising. OBJECTIVE Identify and synthesise literature on educating healthcare students and practitioners about digital professionalism on social media. METHOD Four databases i.e., CINAHL, ERIC, MEDLINE and PubMed were searched using relevant terms. Five hundred and twenty-two articles were found and screened. Data extraction and critical appraisal were conducted. Analysis followed Braun and Clarke's six phases of thematic analysis. RESULTS Eleven studies were included in the review. Digital professionalism was taught across medicine, nursing, and allied health education using a number of pedagogical approaches including traditional face-to-face teaching, as well as fully online, and blended methods. Its impact on learning centred on acquiring knowledge about communicating appropriately on social media which appeared to change how some students and practitioners behaved online, while improving confidence and information literacy. Developing and delivering education on digital professionalism tended to be affected by the amount of time faculty and trainers had to create curricula, organise and deliver teaching, and support students and clinicians. The design of the online platform seemed to be important as some had more functionality than others, allowing for greater interaction, which appeared to keep learners engaged. DISCUSSION AND CONCLUSION This review provides the first synthesis of literature on educating the medical, nursing, and allied health professions on digital professionalism on social media. The results identify potential issues, knowledge gaps, and highlight implications for future educational interventions. Recommendations include setting clear boundaries and pedagogical instructions, understanding and applying privacy settings online, and utilising co-creation approaches with students and practitioners to improve the quality of health education.
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Affiliation(s)
- Siobhan O'Connor
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.
| | - Mengying Zhang
- School of Health in Social Science, The Edinburgh of University, Edinburgh, United Kingdom.
| | - Michelle Honey
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Jung Jae Lee
- School of Nursing, The University of Hong Kong, Hong Kong, Hong Kong.
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15
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Du T, Xie L, Zhang H, Liu X, Wang X, Chen D, Xu Y, Sun Z, Zhou W, Song L, Guan C, Lansky AJ, Xu B. Training and validation of a deep learning architecture for the automatic analysis of coronary angiography. EUROINTERVENTION 2021; 17:32-40. [PMID: 32830647 PMCID: PMC9753915 DOI: 10.4244/eij-d-20-00570] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND In recent years, the use of deep learning has become more commonplace in the biomedical field and its development will greatly assist clinical and imaging data interpretation. Most existing machine learning methods for coronary angiography analysis are limited to a single aspect. AIMS We aimed to achieve an automatic and multimodal analysis to recognise and quantify coronary angiography, integrating multiple aspects, including the identification of coronary artery segments and the recognition of lesion morphology. METHODS A data set of 20,612 angiograms was retrospectively collected, among which 13,373 angiograms were labelled with coronary artery segments, and 7,239 were labelled with special lesion morphology. Trained and optimised by these labelled data, one network recognised 20 different segments of coronary arteries, while the other detected lesion morphology, including measures of lesion diameter stenosis as well as calcification, thrombosis, total occlusion, and dissection detections in an input angiogram. RESULTS For segment prediction, the recognition accuracy was 98.4%, and the recognition sensitivity was 85.2%. For detecting lesion morphologies including stenotic lesion, total occlusion, calcification, thrombosis, and dissection, the F1 scores were 0.829, 0.810, 0.802, 0.823, and 0.854, respectively. Only two seconds were needed for the automatic recognition. CONCLUSIONS Our deep learning architecture automatically provides a coronary diagnostic map by integrating multiple aspects. This helps cardiologists to flag and diagnose lesion severity and morphology during the intervention.
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Affiliation(s)
- Tianming Du
- Beijing University of Posts and Telecommunications, Beijing, China
| | - Lihua Xie
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Honggang Zhang
- Beijing University of Posts and Telecommunications, Beijing, China
| | - Xuqing Liu
- Beijing University of Posts and Telecommunications, Beijing, China
| | - Xiaofei Wang
- Beijing Redcdn Technology Co., Ltd, Beijing, China
| | - Donghao Chen
- Beijing Redcdn Technology Co., Ltd, Beijing, China
| | - Yang Xu
- Beijing Redcdn Technology Co., Ltd, Beijing, China
| | - Zhongwei Sun
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Wenhui Zhou
- Beijing Redcdn Technology Co., Ltd, Beijing, China
| | - Lei Song
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Changdong Guan
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | | | - Bo Xu
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, A 167, Beilishi Road, Xicheng District, Beijing, 100037, China
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16
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Quantified electronic health record (EHR) use by academic surgeons. Surgery 2021; 169:1386-1392. [PMID: 33483138 DOI: 10.1016/j.surg.2020.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/30/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The electronic health record has improved medical billing, research, and sharing of patient data, but its clinical use by physicians has been linked to rising physician burnout leading to numerous subjective editorials about the electronic health record inefficiencies and detriment to frontline caregivers. This study aimed to quantify electronic health record use by surgeons. METHODS The study is a retrospective review and descriptive analysis of deidentified electronic health record data from September 2016 to June 2017. A binary time series was created for each attending to calculate electronic health record system login times. The primary outcome was the total amount of time a surgeon logged into the electronic health record system during the study period. RESULTS Fifty-one general surgery attendings (31 males, 20 females), spanning 9 specialties spent a mean of 2.0 hours per day and 13.8 hours per week logged into the electronic health record. The top 15% of users were logged in for an average of 4.6 hours per weekday. Sixty-five percent of overall electronic health record use occurred on-site, and 35% was remote. A greater proportion of remote use occurred during nighttime hours and Sundays. Clinic days required the largest amount of electronic health record use time compared with operating room and administrative days. CONCLUSION General surgery attendings spend a considerable amount of time using the electronic health record. Ultimately, the goal of these quantitative electronic health record results is to correlate with burnout and job satisfaction data to facilitate the implementation of programs to improve efficiency and decrease the burden of charting. Further investigation needs to focus on subgroups who are high electronic health record users to better identify the barriers to efficient electronic health record use.
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Rowlands S, Tariq A, Coverdale S, Walker S, Wood M. A qualitative investigation into clinical documentation: why do clinicians document the way they do? HEALTH INF MANAG J 2020; 51:126-134. [PMID: 32643428 DOI: 10.1177/1833358320929776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical documentation is a fundamental component of patient care. The transition from paper based to electronic medical records/electronic health records has highlighted a number of issues associated with documentation practices including duplication. Developing new ways to document the care provided to patients and in turn, persuading clinicians to accept a change, must be supported by evidence that a change is required. In Australia, there has been a limited number of studies exploring the clinical documentation practices and beliefs of clinicians. OBJECTIVE To gain an in-depth understanding of clinician documentation practices. METHOD A qualitative design using semi-structured interviews with clinicians (allied health professionals, doctors (physicians) and nurses) working in a tertiary-level hospital in South-East Queensland, Australia. RESULTS Several themes emerged from the data: environmental factors, including departmental policy and systemic issues, and personal factors, including verification, clinical reasoning and experience influencing documentation practices. CONCLUSION Our study identified that the documentation practices of clinicians are complex, being driven by both environmental and systemic factors and personal factors. This in turn leads to duplication and some redundancy. The documentation burden of duplication could be reduced by changes in policy, supported by multidisciplinary documentation procedures and electronic systems aligned with clinician workflows, while retaining some flexible documentation practices. The documentation practices of individuals, when considered from the perspective of enhancing quality care, are considered legitimate and therefore will continue to form part of the health (medical) record regardless of the format.
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Affiliation(s)
| | - Amina Tariq
- Queensland University of Technology, Australia
| | | | - Sue Walker
- Queensland University of Technology, Australia
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Combination of National Quality Assurance Data Collection With a Standard Operating Procedure in Community-Acquired Pneumonia: A Win-Win Strategy? Qual Manag Health Care 2020; 28:176-182. [PMID: 31246781 DOI: 10.1097/qmh.0000000000000220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The primary contact for German physicians with national quality assurance in community-acquired pneumonia (CAP) is frequently experienced as time-consuming obligatory documentation. Since the regular feedback loop stretches up to 18 months, the immediate impact on quality is perceived as rather low. Ultimately, a method leading to increase in the quality of data collection, clarification on expected clinical treatment standards, and improvement in the acceptance and feedback mechanism is needed. METHODS We developed a form merging data collection for quality indicators with a standard operating procedure (SOP) in CAP and implemented it in the daily routine of a university's department for internal medicine. Fulfillment of quality indicators before and after the implementation of the new form was measured. RESULTS Critical parameters such as the documentation of breathing rate and clinical parameters at discharge strongly improved after implementation of the intervention. Uncritical parameters showed slight improvement or stable results at a high level. CONCLUSION The combination of collection of quality data with a clinical SOP and context information may improve the impact of quality measures by increasing acceptance, quality of data capture, short-loop feedback, and possibly quality of care.
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Overhage JM, McCallie D. Physician Time Spent Using the Electronic Health Record During Outpatient Encounters: A Descriptive Study. Ann Intern Med 2020; 172:169-174. [PMID: 31931523 DOI: 10.7326/m18-3684] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The amount of time that providers spend using electronic health records (EHRs) to support the care delivery process is a concern for the U.S. health care system. Given the potential effect on patient care and the high costs related to this time, particularly for medical specialists whose work is largely cognitive, these findings warrant more precise documentation of the time physicians invest in these clinically focused EHR functions. OBJECTIVE To describe how much time ambulatory medical subspecialists and primary care physicians across several U.S. care delivery systems spend on various EHR functions. DESIGN Descriptive study. SETTING U.S.-based, adult, nonsurgical, ambulatory practices using the Cerner Millennium EHR. PARTICIPANTS 155 000 U.S. physicians. MEASUREMENTS Data were extracted from software log files in the Lights On Network (Cerner) during 2018 that totaled the time spent on each of the 13 clinically focused EHR functions. Averages per encounter by specialty were computed. RESULTS This study included data from approximately 100 million patient encounters with about 155 000 physicians from 417 health systems. Physicians spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33%), documentation (24%), and ordering (17%) functions accounting for most of the time. The distribution of time spent by providers using EHRs varies greatly within specialty. The proportion of time spent on various clinically focused functions was similar across specialties. LIMITATION Variation by health system could not be examined, and all providers used the same software. CONCLUSION The time spent using EHRs to support care delivery constitutes a large portion of the physicians' day, and wide variation suggests opportunities to optimize systems and processes. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
| | - David McCallie
- Cerner Corporation, Kansas City, Missouri (J.M.O., D.M.)
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Abbott PA, Weinger MB. Health information technology:Fallacies and Sober realities - Redux A homage to Bentzi Karsh and Robert Wears. APPLIED ERGONOMICS 2020; 82:102973. [PMID: 31677422 DOI: 10.1016/j.apergo.2019.102973] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 08/27/2019] [Accepted: 10/03/2019] [Indexed: 06/10/2023]
Abstract
Since the publication of "Health Information Technology: Fallacies and Sober Realities" in 2010, health information technology (HIT) has become nearly ubiquitous in US healthcare facilities. Yet, HIT has yet to achieve its putative benefits of higher quality, safer, and lower cost care. There has been variable but largely marginal progress at addressing the 12 HIT fallacies delineated in the original paper. Here, we revisit several of the original fallacies and add five new ones. These fallacies must be understood and addressed by all stakeholders for HIT to be a positive force in achieving the high value healthcare system the nation deserves. Foundational cognitive and human factors engineering research and development continue to be essential to HIT development, deployment, and use.
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Affiliation(s)
- Patricia A Abbott
- Department of Systems, Populations and Leadership, USA; Department of Leadership, Analytics, & Innovation, University of Michigan, School of Nursing, USA.
| | - Matthew B Weinger
- Departments of Anesthesiology, Biomedical Informatics, and Medical Education, Vanderbilt University School of Medicine, USA; Geriatric Research Education and clinical Center, VA Tennessee Valley Healthcare System, USA.
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Abstract
Medical and epidemiological documentation in disasters is pivotal: the former for recording patient care and the latter for providing real-time information to the host country. Furthermore, documentation informs post-hoc analysis to improve the effectiveness of future deployments.Although documentation is considered important and indeed integral to health care response, there are many barriers and challenges. Some of these challenges include: working without well-established standards for medical documentation; and working with international guidelines which provide minimal guidance as to how health data should be managed practically to ensure accuracy and completion. Furthermore, there is a shift in mindset in disaster contexts wherein most health care focus shifts to direct clinical care and diverts almost all attention from quality documentation.This report distinguishes between the tasks of the epidemiologist and the data manager (DM) in an emergency medical team (EMT) and discusses the importance of data collection in the specific case of an EMT deployment. While combining these roles is sometimes possible if resources are limited, it is better to separate them, as the two are quite distinct. Although there is overlap, to achieve the goals of either role, preferentially they should be carried out by two people working closely together with complementary skill sets. The main objective of this report is to provide guidance and task descriptions to EMTs and field hospitals when training, recruiting, and preparing DMs and epidemiologists to work within their teams. Clear delineation of tasks will lead to better quality data, as it commits DMs to being concerned with the provision of real-time documentation from patient arrival through to compiling daily reports. It also commits epidemiologists to providing enhanced disease surveillance; outbreak investigation; and a source of reliable and actionable information for decision makers and stakeholders in the disaster management cycle.
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Flieger SP, Thomas CP, Prottas J. Improving Interorganizational Coordination Between Primary Care and Oncology: Adapting a Chronic Care Management Model for Patients With Cancer. Med Care Res Rev 2019; 78:229-239. [PMID: 31462141 DOI: 10.1177/1077558719870699] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to explore the implementation of a payment and delivery system innovation to improve coordination and communication between primary care and oncology. We employed a qualitative case study approach, conducting interviews (n = 18), and reviewing archival materials. Chronic care coordinators and the cancer center social worker acted as boundary spanners. The chronic care coordinator role built on medical home infrastructure, applying the chronic care model to cancer care. Coordination from primary care to oncology became more routinized, with information sharing prompted by specific events. These new boundary spanner roles enabled greater coordination around uncertain and interdependent tasks. Recommendations for scaling up include the following: establish systematic approaches to learning from implementation, leverage existing capacity for scalability, and attend to the content and purpose of information sharing.
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Kentgen M, Varghese J, Samol A, Waltenberger J, Dugas M. Common Data Elements for Acute Coronary Syndrome: Analysis Based on the Unified Medical Language System. JMIR Med Inform 2019; 7:e14107. [PMID: 31444871 PMCID: PMC6729118 DOI: 10.2196/14107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/21/2019] [Accepted: 07/04/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Standardization in clinical documentation can increase efficiency and can save time and resources. OBJECTIVE The objectives of this work are to compare documentation forms for acute coronary syndrome (ACS), check for standardization, and generate a list of the most common data elements using semantic form annotation with the Unified Medical Language System (UMLS). METHODS Forms from registries, studies, risk scores, quality assurance, official guidelines, and routine documentation from four hospitals in Germany were semantically annotated using UMLS. This allowed for automatic comparison of concept frequencies and the generation of a list of the most common concepts. RESULTS A total of 3710 forms items from 86 sources were semantically annotated using 842 unique UMLS concepts. Half of all medical concept occurrences were covered by 60 unique concepts, which suggests the existence of a core dataset of relevant concepts. Overlap percentages between forms were relatively low, hinting at inconsistent documentation structures and lack of standardization. CONCLUSIONS This analysis shows a lack of standardized and semantically enriched documentation for patients with ACS. Efforts made by official institutions like the European Society for Cardiology have not yet been fully implemented. Utilizing a standardized and annotated core dataset of the most important data concepts could make export and automatic reuse of data easier. The generated list of common data elements is an exemplary implementation suggestion of the concepts to use in a standardized approach.
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Affiliation(s)
- Markus Kentgen
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Julian Varghese
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Alexander Samol
- Medical Faculty, University Hospital of Münster, Münster, Germany
| | | | - Martin Dugas
- Institute of Medical Informatics, University of Münster, Münster, Germany
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Zhu X, Tu SP, Sewell D, Yao NA, Mishra V, Dow A, Banas C. Measuring electronic communication networks in virtual care teams using electronic health records access-log data. Int J Med Inform 2019; 128:46-52. [PMID: 31160011 DOI: 10.1016/j.ijmedinf.2019.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/01/2019] [Accepted: 05/11/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To develop methods for measuring electronic communication networks in virtual care teams using electronic health records (EHR) access-log data. METHODS For a convenient sample of 100 surgical colorectal cancer patients, we used time-stamped EHR access-log data extracted from an academic medical center's EHR system to construct communication networks among healthcare professionals (HCPs) in each patient's virtual care team. We measured communication linkages between HCPs using the inverse of the average time between access events in which the source HCPs sent information to and the destination HCPs retrieved information from the EHR system. Social network analysis was used to examine and visualize communication network structures, identify principal care teams, and detect meaningful structural differences across networks. We conducted a non-parametric multivariate analysis of variance (MANOVA) to test the association between care teams' communication network structures and patients' cancer stage and site. RESULTS The 100 communication networks showed substantial variations in size and structures. Principal care teams, the subset of HCPs who formed the core of the communication networks, had higher proportions of nurses, physicians, and pharmacists and a lower proportion of laboratory medical technologists than the overall networks. The distributions of conditional uniform graph quantiles suggested that our network-construction technique captured meaningful underlying structures that were different from random unstructured networks. MANOVA results found that the networks' topologies were associated with patients' cancer stage and site. CONCLUSIONS This study demonstrates that it is feasible to use EHR access-log data to measure and examine communication networks in virtual care teams. The proposed methods captured salient communication patterns in care teams that were associated with patients' clinical differences.
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Affiliation(s)
- Xi Zhu
- University of Iowa, Department of Health Management and Policy, 145 N Riverside Dr, N222, Iowa City, IA 52242, United States.
| | - Shin-Ping Tu
- University of California Davis, Department of Internal Medicine, Davis, CA, United States
| | - Daniel Sewell
- University of Iowa, Department of Biostatistics, Iowa City, IA, United States
| | - Nengliang Aaron Yao
- University of Virginia, Department of Public Health Sciences, Charlottesville, VA, United States
| | - Vimal Mishra
- Virginia Commonwealth University, Department of Internal Medicine, Richmond, VA, United States
| | - Alan Dow
- Virginia Commonwealth University, Department of Internal Medicine, Richmond, VA, United States
| | - Colin Banas
- Virginia Commonwealth University, Department of Internal Medicine, Richmond, VA, United States
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Nurses "Seeing Forest for the Trees" in the Age of Machine Learning: Using Nursing Knowledge to Improve Relevance and Performance. Comput Inform Nurs 2019; 37:203-212. [PMID: 30688670 DOI: 10.1097/cin.0000000000000508] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although machine learning is increasingly being applied to support clinical decision making, there is a significant gap in understanding what it is and how nurses should adopt it in practice. The purpose of this case study is to show how one application of machine learning may support nursing work and to discuss how nurses can contribute to improving its relevance and performance. Using data from 130 specialized hospitals with 101 766 patients with diabetes, we applied various advanced statistical methods (known as machine learning algorithms) to predict early readmission. The best-performing machine learning algorithm showed modest predictive ability with opportunities for improvement. Nurses can contribute to machine learning algorithms by (1) filling data gaps with nursing-relevant data that provide personalized context about the patient, (2) improving data preprocessing techniques, and (3) evaluating potential value in practice. These findings suggest that nurses need to further process the information provided by machine learning and apply "Wisdom-in-Action" to make appropriate clinical decisions. Nurses play a pivotal role in ensuring that machine learning algorithms are shaped by their unique knowledge of each patient's personalized context. By combining machine learning with unique nursing knowledge, nurses can provide more visibility to nursing work, advance nursing science, and better individualize patient care. Therefore, to successfully integrate and maximize the benefits of machine learning, nurses must fully participate in its development, implementation, and evaluation.
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Zhao JY, Kessler EG, Guo WA. Interprofessional Communication Goes Up When the Electronic Health Record Goes Down. JOURNAL OF SURGICAL EDUCATION 2019; 76:512-518. [PMID: 30253982 DOI: 10.1016/j.jsurg.2018.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/15/2018] [Accepted: 08/23/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The electronic health record (EHR) has been faulted for the erosion of interprofessional communication and the patient-physician relationship. Surgical residents may be susceptible to communication workarounds facilitated by the EHR, but the full extent is not well understood. A recent ransomware attack with the abrupt return to paper charting provided a unique opportunity to investigate the impact of the EHR on surgical residents' interprofessional communication. We sought to explore how surgical residents perceived communications during the 2-month period when the EHR was inaccessible. DESIGN General surgery residents who rotated through the regional tertiary referral medical center and level I trauma center were invited to participate in a semistructured interview about communication with one another, faculty, staff, and patients during the downtime. A grounded theory approach was used to analyze the data. SETTING Regional tertiary referral medical center and level I trauma center. PARTICIPANTS General surgery residents who rotated through the affected site. RESULTS Ten general surgery residents were interviewed. Interviews revealed that the abrupt loss of the EHR impacted communication in three major ways: (1) engendered more professional courtesy and collegiality, (2) prioritized bedside patient care over documentation demands, and (3) encouraged more explicit and deliberate communications. CONCLUSIONS Our study demonstrates that the loss of the EHR encourages surgery residents interprofessional communication. With healthcare becoming increasingly digital, active efforts should be made to preserve the communication benefits by optimizing existing and emerging technology to facilitate direct face-to-face interactions.
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Affiliation(s)
- Jane Y Zhao
- Department of Surgery, University at Buffalo, State University of New York, Buffalo, New York; Department of Biomedical Informatics, University at Buffalo, State University of New York, Buffalo, New York.
| | - Evan G Kessler
- Department of Surgery, University at Buffalo, State University of New York, Buffalo, New York; Department of Epidemiology and Environmental Health, University at Buffalo, State University of New York, Buffalo, New York.
| | - Weidun A Guo
- Department of Surgery, University at Buffalo, State University of New York, Buffalo, New York.
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Gray LC, Beattie E, Boscart VM, Henderson A, Hornby-Turner YC, Hubbard RE, Wood S, Peel NM. Development and Testing of the interRAI Acute Care: A Standardized Assessment Administered by Nurses for Patients Admitted to Acute Care. Health Serv Insights 2018; 11:1178632918818836. [PMID: 30618486 PMCID: PMC6299328 DOI: 10.1177/1178632918818836] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/16/2018] [Indexed: 11/21/2022] Open
Abstract
Background: Underpinning standards for developing comprehensive care in hospital is the need to identify, early in the admission process, functional and psychosocial issues which affect patient outcomes. Despite the value of comprehensive assessment of patients on admission, the process is often sub-optimal due to a lack of standardized assessment practices. This project aimed to develop a concise, integrated assessment for patients admitted to acute care and test its psychometric properties. Methods: Two international expert panels of clinicians and health scientists collaborated to establish design parameters. Using clinical observations and a variety of derivative applications sourced from the interRAI research collaborative repository, the panels constructed a draft instrument to examine feasibility, resource requirements, and inter-rater reliability. Field testing was conducted in Australia and Canada. Next, the system was revised to its final form, the interRAI Acute Care, after feedback and review from international interRAI members. Results: Constructed using 56 items, the interRAI Acute Care required a median of 15 minutes to complete. Inter-rater reliability tested on 130 paired assessments was substantial to almost perfect for 78% of the clinical items and moderate for the remaining 22% of items. A subset of 30 items from the admission assessment comprised the discharge assessment. Discussion: The interRAI Acute Care has been shown to be an efficient nursing assessment instrument with good psychometric properties. Implementation in a digital environment will enable documentation and care planning to comply with standards for quality of care in the general adult hospital population.
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Affiliation(s)
- Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Elizabeth Beattie
- School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Veronique M Boscart
- Schlegel Centre for Advancing Seniors Care, Conestoga College, Kitchener, ON, Canada
| | - Amanda Henderson
- Nursing Practice Development Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Yvonne C Hornby-Turner
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Ruth E Hubbard
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Susan Wood
- Quality and Patient Safety, Canterbury and West Coast District Health Boards, Christchurch, New Zealand
| | - Nancye M Peel
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Zhao JY, Kessler EG, Yu J, Jalal K, Cooper CA, Brewer JJ, Schwaitzberg SD, Guo WA. Impact of Trauma Hospital Ransomware Attack on Surgical Residency Training. J Surg Res 2018; 232:389-397. [PMID: 30463746 DOI: 10.1016/j.jss.2018.06.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/01/2018] [Accepted: 06/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND A recent ransomware attack led to the shutdown of the electronic health information system (HIS) at our trauma center for 2 mo. We investigated its impact on residency training during the downtime. MATERIAL AND METHODS General and orthopedic surgical residents who rotated at the hospital were invited to participate in a survey regarding their patient care and residency training experiences during the downtime. Attending surgeons from both the specialties were invited to participate in a semistructured interview regarding their attitude toward residency training during the downtime. RESULTS Twenty-nine residents responded to the survey with a response rate of 78.4%. Residents acknowledged significant increases in face-to-face communication and decreases in use of online educational resources during the downtime (P < 0.01). Residents were significantly stressed by the dearth of online resources (P < 0.0001) and by paper-based orders and outpatient clinic (P < 0.05). A multivariate analysis demonstrated an inverse relationship between postgraduate year and stress from paper orders (P = 0.003). Attending surgeon's interviews revealed that they recognized residents' unpreparedness and strove harder to teach more effectively. CONCLUSIONS Our study demonstrated that an unexpected shutdown of the hospital HIS imposed significant stress upon surgical residents providing trauma patient care and made attending surgeons take greater efforts to be more effective teachers. Residents who are digital natives lack adaptability to handle a paper-based workflow. With cyber security threats increasing in health care, preparedness should be included in the graduate medical education curriculum.
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Affiliation(s)
- Jane Y Zhao
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Evan G Kessler
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, New York
| | - Jihnhee Yu
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, New York
| | - Kabir Jalal
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, New York
| | - Clairice A Cooper
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Jeffrey J Brewer
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Steven D Schwaitzberg
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Weidun Alan Guo
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.
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Cox ML, Farjat AE, Risoli TJ, Peskoe S, Goldstein BA, Turner DA, Migaly J. Documenting or Operating: Where Is Time Spent in General Surgery Residency? JOURNAL OF SURGICAL EDUCATION 2018; 75:e97-e106. [PMID: 30522828 PMCID: PMC10765321 DOI: 10.1016/j.jsurg.2018.10.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/25/2018] [Accepted: 10/11/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The utilization of electronic health records (EHR) has become essential in the daily activities of physicians for documentation and as an information source. However, the amount of time spent by residents utilizing the EHR has not been thoroughly evaluated, particularly within surgical specialties. This study aims to analyze EHR usage by general surgery residents and to assess the association between this use and case volume at a single academic institution. DESIGN For general surgery residents in clinical years (CY) 1-5, de-identified login and logout time data between September 2016 and June 2017 were retrospectively extracted from the Epic EHR (Verona, WI). A binary time series was created for each resident to indicate and track over time whether he or she was utilizing the EHR system. Comparisons between categorical variables were performed with Fisher's exact test. Continuous variables were compared using Wilcoxon rank sum test. Longitudinal linear mixed-effects models were used to assess the EHR usage among the surgery residents. The association between EHR time and the number of operative cases logged was evaluated with Pearson's correlation coefficient. SETTING This study was performed by the Department of Surgery in conjunction with the Office of Graduate Medical Education at Duke University Health System. PARTICIPANTS All active general surgery residents during the 2016-2017 academic year. RESULTS Thirty-six general surgery residents (28 males, 8 females) spent a median of 2.4 hours per day and 23.7 hours per week using the EHR. CY2 had the highest median usage per week (28.9 hours), while CY3 had the lowest (16.7 hours) but no significant difference based on EHR usage was found among the analyzed CYs (p = 0.164). Residents spent significantly more time logged into the EHR during the week compared to weekends and during the day compared to nights (all p < 0.001). For the residency program as a whole, a median of 151.5 total work hours per day was dedicated to documentation. On average, interns on dedicated night rotations spent 7% of their login time outside regularly scheduled duty hours while interns on dedicated day rotations spent 27%. There was no overall correlation between monthly case logs and EHR usage (r = 0.06, p = 0.30); however, CY2 had a significant negative correlation (r = -0.2, p = 0.038). CONCLUSIONS In the era of a maximum 80-hour work week, general surgery residents spend a substantial portion, at least 30%, of their time utilizing the EHR. One third of EHR usage by interns occurred outside the scheduled 12-hour shift, demonstrating the difficulties of completing paperwork as part of the scheduled work day. Additionally, the lack of correlation to case logs is likely due to an underestimation of the documentation burden associated with operating, which includes preparatory effort and operative notes. Ultimately, these quantitative EHR usage results will be correlated to burnout prior to implementing programs to improve efficiency and decrease the burden of charting.
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Affiliation(s)
- Morgan L Cox
- Department of Surgery, Duke University, Durham, North Carolina.
| | - Alfredo E Farjat
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - T J Risoli
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Sarah Peskoe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - David A Turner
- Graduate Medical Education, Duke University Hospital and Health System, Durham, North Carolina
| | - John Migaly
- Department of Surgery, Duke University, Durham, North Carolina
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Chalikonda L, Phelan N, O'Byrne J. An assessment of the quality of clinical records in elective orthopaedics using the STAR score. Ir J Med Sci 2018; 188:849-853. [PMID: 30343353 DOI: 10.1007/s11845-018-1918-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 10/13/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Litigation claims related to surgery have increased significantly in recent years. Despite the medico-legal importance of clinical records, there have been few published studies describing the quality of medical records in orthopaedic surgery. This study aimed to evaluate the quality of clinical note taking in an elective orthopaedic setting over a 10-year period by comparing medical records from 2003 and 2013. METHODS We used the previously validated Surgical Tool for Auditing Records (STAR) on a sample of 20 medical records from each year. We performed statistical analysis to determine if significant differences existed between 2003 and 2013. RESULTS There was an overall improvement in the quality of medical records from 76.7% (range 68-82%) in 2003, to 81% (range 72-88%) in 2013 (P value < 0.05). There were significant improvements in the subsequent entry score, from 5.15 to 6.3 (P value < 0.05) and discharge summary score, 6.65 to 7.95 (P value < 0.05). The score for the operative record section decreased from 8.45 to 8.0 (P value < 0.05). CONCLUSION The overall standard of medical records in both 2003 and 2013 was high and comparable to other surgical specialties. There was no possible correlation observed between standards of medical records and increasing litigation claims in surgery. Widespread implementation of Electronic Medical Records (EMRs) is likely to have a significant impact on the quality of medical records. Further research is required to determine how the design of EMRs influences how healthcare professionals record data.
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Affiliation(s)
| | - Nigel Phelan
- Royal College of Surgeons Ireland, Dublin, Ireland
| | - John O'Byrne
- Royal College of Surgeons Ireland, Dublin, Ireland
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Roy CG. Value-Based Purchasing for Hospital-Acquired Venous Thromboembolism: Too Much, Too Soon. J Hosp Med 2018; 13:505-506. [PMID: 29694461 DOI: 10.12788/jhm.2969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Christopher G Roy
- Mount Auburn Hospital, Cambridge, Massachusetts; Harvard Medical School, Cambridge, Massachusetts, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
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The Role of the Electronic Medical Record in the Intensive Care Unit Nurse's Detection of Patient Deterioration: A Qualitative Study. Comput Inform Nurs 2018; 36:284-292. [PMID: 29601339 DOI: 10.1097/cin.0000000000000431] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Failure to detect patient deterioration signals leads to longer stays in the hospital, worse functional outcomes, and higher hospital mortality rates. Surveillance, including ongoing acquisition, interpretation, and synthesis of patient data by the nurse, is essential for early risk detection. Electronic medical records promote accessibility and retrievability of patient data and can support patient surveillance. A secondary analysis was performed on interview data from 24 intensive care unit nurses, collected in a study that examined factors influencing nurse responses to alarms. Six themes describing nurses' use of electronic medical record information to understand the patients' norm and seven themes describing electronic medical record design issues were identified. Further work is needed on electronic medical record design to integrate documentation and information presentation with the nursing workflow. Organizations should involve bedside nurses in the design of handoff formats that provide key information common to all intensive care unit patient populations, as well as population-specific information.
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Torsvik T, Lillebo B, Hertzum M. How Do Experienced Physicians Access and Evaluate Laboratory Test Results for the Chronic Patient? A Qualitative Analysis. Appl Clin Inform 2018; 9:403-410. [PMID: 29874686 PMCID: PMC5990424 DOI: 10.1055/s-0038-1653967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 04/07/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Electronic health records may present laboratory test results in a variety of ways. Little is known about how the usefulness of different visualizations of laboratory test results is influenced by the complex and varied process of clinical decision making. OBJECTIVE The purpose of this study was to investigate how clinicians access and utilize laboratory test results when caring for patients with chronic illness. METHODS We interviewed 10 attending physicians about how they access and assess laboratory tests when following up patients with chronic illness. The interviews were audio-recorded, transcribed verbatim, and analyzed qualitatively. RESULTS Informants preferred different visualizations of laboratory test results, depending on what aspects of the data they were interested in. As chronic patients may have laboratory test results that are permanently outside standardized reference ranges, informants would often look for significant change, rather than exact values. What constituted significant change depended on contextual information (e.g., the results of other investigations, intercurrent diseases, and medical interventions) spread across multiple locations in the electronic health record. For chronic patients, the temporal relations between data could often be of special interest. Informants struggled with finding and synthesizing fragmented information into meaningful overviews. CONCLUSION The presentation of laboratory test results should account for the large variety of associated contextual information needed for clinical comprehension. Future research is needed to improve the integration of the different parts of the electronic health record.
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Affiliation(s)
- Torbjørn Torsvik
- Department of Neuroscience, Faculty of Medicine and Health Sciences, Norwegian EPR Research Centre, Norwegian University of Science and Technology, Trondheim, Norway
| | - Børge Lillebo
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Morten Hertzum
- Department of Information Studies, University of Copenhagen, Copenhagen, Denmark
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Inokuchi R, Maehara H, Iwai S, Iwagami M, Sato H, Yamaguchi Y, Asada T, Yamamoto M, Nakamura K, Hiruma T, Doi K, Morimura N. Interface design dividing physical findings into medical and trauma findings facilitates clinical document entry in the emergency department: A prospective observational study. Int J Med Inform 2018; 112:143-148. [PMID: 29500012 DOI: 10.1016/j.ijmedinf.2018.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 01/21/2018] [Accepted: 01/24/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE The interface design and its effect on workflow are key determinants of the usability of electronic medical records (EMRs) in the emergency department (ED). However, whether the overall clinical care can be improved by dividing the interface design of physical findings into medical and trauma findings is unknown. We previously developed an EMR system in which the checkpoints were separated into different sections according to the body part. Herein, we modified this EMR system by remaking the interface design specifically for trauma patients, and evaluated its performance. METHODS This study was undertaken in a single-center ED between October 2014 and September 2015. In the modified EMR system, all trauma findings are displayed together on the screen, according to the Japan Advanced Trauma Evaluation and Care. We compared the time to final documentation entry and the length of ED stay between the previous (used in the first 6 months) and current systems (used in the latter 6 months). Furthermore, we stratified the patients by triage levels. RESULTS The study involved 2141 patients (934 and 1207 assessed using the previous and modified EMR systems, respectively). The modified EMR in trauma patients significantly decreased the time to final documentation entry from 131.5 [interquartile range, 86.8-207.3] to 115 [78.8-161] min (p = 0.049). When stratifying trauma patients by triage level, significantly shorter clinical documentation times were observed with the modified EMR system in levels 2 (emergency) and 3 (urgent). CONCLUSIONS Using different interfaces for trauma findings shortened the time for clinical documentation for trauma patients.
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Affiliation(s)
- Ryota Inokuchi
- Department of Acute Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; Department of Emergency and Critical Care Medicine, JR Tokyo General Hospital, Yoyogi, Shibuya-ku, Tokyo, Japan.
| | - Hiromu Maehara
- Department of Acute Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; Department of Emergency and Critical Care Medicine, JR Tokyo General Hospital, Yoyogi, Shibuya-ku, Tokyo, Japan
| | - Satoshi Iwai
- Department of Acute Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masao Iwagami
- London School of Hygiene and Tropical Medicine, Keppel St., Bloomsbury, London WC1E 7HT, United Kingdom
| | - Hajime Sato
- Department of Health Policy and Technology Assessment, National Institute of Public Health, 2-3-6 Minami, Wako, Saitama 351-0197, Japan
| | - Yoko Yamaguchi
- Department of Emergency and Critical Care Medicine, JR Tokyo General Hospital, Yoyogi, Shibuya-ku, Tokyo, Japan
| | - Toshifumi Asada
- Department of Acute Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Miyuki Yamamoto
- Department of Acute Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kensuke Nakamura
- Department of Acute Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Takahiro Hiruma
- Department of Acute Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Naoto Morimura
- Department of Acute Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Morawski K, Childs-Roshak J, Weitberg A. Scribes: Re-writing the story on patient and provider experience. Healthcare (Basel) 2017; 5:95-97. [DOI: 10.1016/j.hjdsi.2017.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 02/23/2017] [Accepted: 04/05/2017] [Indexed: 11/25/2022] Open
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Meystre SM, Lovis C, Bürkle T, Tognola G, Budrionis A, Lehmann CU. Clinical Data Reuse or Secondary Use: Current Status and Potential Future Progress. Yearb Med Inform 2017; 26:38-52. [PMID: 28480475 PMCID: PMC6239225 DOI: 10.15265/iy-2017-007] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Indexed: 12/30/2022] Open
Abstract
Objective: To perform a review of recent research in clinical data reuse or secondary use, and envision future advances in this field. Methods: The review is based on a large literature search in MEDLINE (through PubMed), conference proceedings, and the ACM Digital Library, focusing only on research published between 2005 and early 2016. Each selected publication was reviewed by the authors, and a structured analysis and summarization of its content was developed. Results: The initial search produced 359 publications, reduced after a manual examination of abstracts and full publications. The following aspects of clinical data reuse are discussed: motivations and challenges, privacy and ethical concerns, data integration and interoperability, data models and terminologies, unstructured data reuse, structured data mining, clinical practice and research integration, and examples of clinical data reuse (quality measurement and learning healthcare systems). Conclusion: Reuse of clinical data is a fast-growing field recognized as essential to realize the potentials for high quality healthcare, improved healthcare management, reduced healthcare costs, population health management, and effective clinical research.
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Affiliation(s)
- S. M. Meystre
- Medical University of South Carolina, Charleston, SC, USA
| | - C. Lovis
- Division of Medical Information Sciences, University Hospitals of Geneva, Switzerland
| | - T. Bürkle
- University of Applied Sciences, Bern, Switzerland
| | - G. Tognola
- Institute of Electronics, Computer and Telecommunication Engineering, Italian Natl. Research Council IEIIT-CNR, Milan, Italy
| | - A. Budrionis
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
| | - C. U. Lehmann
- Departments of Biomedical Informatics and Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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Chowdhry SM, Mishuris RG, Mann D. Problem-oriented charting: A review. Int J Med Inform 2017; 103:95-102. [PMID: 28551008 DOI: 10.1016/j.ijmedinf.2017.04.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 04/02/2017] [Accepted: 04/23/2017] [Indexed: 11/29/2022]
Abstract
Problem-oriented charting is form of medical documentation that organizes patient data by a diagnosis or problem. In this review, we discuss the history and current use of problem-oriented charting by critically evaluating the literature on the topic. We provide insights with regard to our own institutional use of problem-oriented charting and potential opportunities for research.
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Affiliation(s)
- Shilpa M Chowdhry
- Department of Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, United States.
| | - Rebecca G Mishuris
- Department of Medicine. Boston University School of Medicine, United States
| | - Devin Mann
- Department of Population Health. NYU School of Medicine, United States
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Triantafillou P. Making electronic health records support quality management: A narrative review. Int J Med Inform 2017; 104:105-119. [PMID: 28599812 DOI: 10.1016/j.ijmedinf.2017.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/05/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Since the 1990s many hospitals in the OECD countries have introduced electronic health record (EHR) systems. A number of studies have examined the factors impinging on EHR implementation. Others have studied the clinical efficacy of EHR. However, only few studies have explored the (intermediary) factors that make EHR systems conducive to quality management (QM). OBJECTIVE Undertake a narrative review of existing studies in order to identify and discuss the factors conducive to making EHR support three dimensions of QM: clinical outcomes, managerial monitoring and cost-effectiveness. METHOD A narrative review of Web of Science, Cochrane, EBSCO, ProQuest, Scopus and three Nordic research databases. LIMITATION most studies do not specify the type of EHR examined. RESULTS 39 studies were identified for analysis. 10 factors were found to be conducive to make EHR support QM. However, the contribution of EHR to the three specific dimensions of QM varied substantially. Most studies (29) included clinical outcomes. However, only half of these reported EHR to have a positive impact. Almost all the studies (36) dealt with the ability of EHR to enhance managerial monitoring of clinical activities, the far majority of which showed a positive relationship. Finally, only five dealt with cost-effectiveness of which two found positive effects. DISCUSSION AND CONCLUSION The findings resonates well with previous reviews, though two factors making EHR support QM seem new, namely: political goals and strategies, and integration of guidelines for clinical conduct. Lacking EHR type specification and diversity in study method imply that there is a strong need for further research on the factors that may make EHR may support QM.
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Klabunde CN, Haggstrom D, Kahn KL, Gray SW, Kim B, Liu B, Eisenstein J, Keating NL. Oncologists' perspectives on post-cancer treatment communication and care coordination with primary care physicians. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28070939 DOI: 10.1111/ecc.12628] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 12/01/2022]
Abstract
Post-treatment cancer care is often fragmented and of suboptimal quality. We explored factors that may affect cancer survivors' post-treatment care coordination, including oncologists' use of electronic technologies such as e-mail and integrated electronic health records (EHRs) to communicate with primary care physicians (PCPs). We used data from a survey (357 respondents; participation rate 52.9%) conducted in 2012-2013 among medical oncologists caring for patients in a large US study of cancer care delivery and outcomes. Oncologists reported their frequency and mode of communication with PCPs, and role in providing post-treatment care. Seventy-five per cent said that they directly communicated with PCPs about post-treatment status and care recommendations for all/most patients. Among those directly communicating with PCPs, 70% always/usually used written correspondence, while 36% always/usually used integrated EHRs; telephone and e-mail were less used. Eighty per cent reported co-managing with PCPs at least one post-treatment general medical care need. In multivariate-adjusted analyses, neither communication mode nor intensity were associated with co-managing survivors' care. Oncologists' reliance on written correspondence to communicate with PCPs may be a barrier to care coordination. We discuss new research directions for enhancing communication and care coordination between oncologists and PCPs, and to better meet the needs of cancer survivors post-treatment.
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Affiliation(s)
- C N Klabunde
- Office of Disease Prevention, Office of the Director, National Institutes of Health, Bethesda, MD, USA
| | - D Haggstrom
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - K L Kahn
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, CA, USA
| | - S W Gray
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - B Kim
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - B Liu
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - J Eisenstein
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - N L Keating
- Department of Health Care Policy, Harvard Medical School and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Wagner-Menghin M, Pokieser P. Information technology and social sciences: how can health IT be used to support the health professional? Ann N Y Acad Sci 2016; 1381:152-161. [PMID: 27637024 DOI: 10.1111/nyas.13220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 08/01/2016] [Accepted: 08/04/2016] [Indexed: 12/21/2022]
Abstract
Keeping up to date with the increasing amount of health-related knowledge and managing the increasing numbers of patients with more complex clinical problems is a challenge for healthcare professionals and healthcare systems. Health IT applications, such as electronic health records or decision-support systems, are meant to support both professionals and their support systems. However, for physicians using these applications, the applications often cause new problems, such as the impracticality of their use in clinical practice. This review adopts a social sciences perspective to understand these problems and derive suggestions for further development. Indeed, humans use tools to remediate the brain's weaknesses and enhance thinking. Available health IT tools have been shaped to fit administrative needs rather than physicians' needs. To increase the beneficial effect of health IT applications in health care, clinicians' style of thinking and their learning needs must be considered when designing and implementing such systems. New health IT tools must be shaped to fit health professionals' needs. To further ease the integration of new health IT tools into clinical practice, we must also consider the effects of implementing new tools on the wider social framework.
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Affiliation(s)
| | - Peter Pokieser
- Medical University of Vienna, Teaching Center, Unified Patient Project, Vienna, Austria
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Chen L, Guo U, Illipparambil LC, Netherton MD, Sheshadri B, Karu E, Peterson SJ, Mehta PH. Racing Against the Clock: Internal Medicine Residents' Time Spent On Electronic Health Records. J Grad Med Educ 2016; 8:39-44. [PMID: 26913101 PMCID: PMC4763387 DOI: 10.4300/jgme-d-15-00240.1] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Since the late 1980s, resident physicians have spent increasing amounts of time on electronic health record (EHR) data entry and retrieval. Objective longitudinal data measuring time spent on the EHR are lacking. OBJECTIVE We sought to quantify the time actually spent using the EHR by all first-year internal medicine residents in a single program (N = 41). METHODS Active EHR usage data were collected from the audit logs for May, July, and October 2014 and January 2015. Per recommendations from our EHR vendor (Cerner Corporation), active EHR usage time was defined as more than 15 keystrokes, or 3 mouse clicks, or 1700 "mouse miles" per minute. Active EHR usage time was tallied for each patient chart viewed each day and termed an electronic patient record encounter (EPRE). RESULTS In 4 months, 41 interns accumulated 18,322 hours of active EHR usage in more than 33,733 EPREs. Each intern spent on average 112 hours per month on 206 EPREs. Interns spent more time in July compared to January (41 minutes versus 30 minutes per EPRE, P < .001). Time spent on the EHR in January echoed that of the previous May (30 minutes versus 29 minutes, P = .40). CONCLUSIONS First-year residents spent a significant amount of time actively using the EHR, achieving maximal proficiency on or before January of the academic year. Decreased time spent on the EHR may reflect greater familiarity with the EHR, growing EHR efficiencies, or other factors.
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Affiliation(s)
| | | | | | | | | | | | | | - Parag H. Mehta
- Corresponding author: Parag H. Mehta, MD, New York Methodist Hospital/Weill Cornell Medical College, 506 Sixth Street, Brooklyn, NY 11215, 718.780.5246, fax 718.780.3259,
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Varpio L, Rashotte J, Day K, King J, Kuziemsky C, Parush A. The EHR and building the patient's story: A qualitative investigation of how EHR use obstructs a vital clinical activity. Int J Med Inform 2015; 84:1019-28. [PMID: 26432683 DOI: 10.1016/j.ijmedinf.2015.09.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/19/2015] [Accepted: 09/11/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Recent research has suggested that using electronic health records (EHRs) can negatively impact clinical reasoning (CR) and interprofessional collaborative practices (ICPs). Understanding the benefits and obstacles that EHR use introduces into clinical activities is essential for improving medical documentation, while also supporting CR and ICP. METHODS This qualitative study was a longitudinal pre/post investigation of the impact of EHR implementation on CR and ICP at a large pediatric hospital. We collected data via observations, interviews, document analysis, and think-aloud/-after sessions. Using constructivist Grounded Theory's iterative cycles of data collection and analysis, we identified and explored an emerging theme that clinicians described as central to their CR and ICP activities: building the patient's story. We studied how building the patient's story was impacted by the introduction and implementation of an EHR. RESULTS Clinicians described the patient's story as a cognitive awareness and overview understanding of the patient's (1) current status, (2) relevant history, (3) data patterns that emerged during care, and (4) the future-oriented care plan. Constructed by consolidating and interpreting a wide array of patient data, building the patient's story was described as a vitally important skill that was required to provide patient-centered care, within an interprofessional team, that safeguards patient safety and clinicians' professional credibility. Our data revealed that EHR use obstructed clinicians' ability to build the patient's story by fragmenting data interconnections. Further, the EHR limited the number and size of free-text spaces available for narrative notes. This constraint inhibited clinicians' ability to read the why and how interpretations of clinical activities from other team members. This resulted in the loss of shared interprofessional understanding of the patient's story, and the increased time required to build the patient's story. CONCLUSIONS We discuss these findings in relation to research on the role of narratives for enabling CR and ICP. We conclude that EHRs have yet to truly fulfill their promise to support clinicians in their patient care activities, including the essential work of building the patient's story.
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Affiliation(s)
- Lara Varpio
- Department of Medicine, Uniformed Services University for the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA; Academy for Innovation in Medical Education, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada.
| | - Judy Rashotte
- Nursing Research, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario, Canada; School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada.
| | - Kathy Day
- Academy for Innovation in Medical Education, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada.
| | - James King
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario, Canada.
| | - Craig Kuziemsky
- Telfer School of Management, University of Ottawa, 55 Laurier Avenue East, Ottawa, Ontario, Canada.
| | - Avi Parush
- Department of Psychology, Carleton University, Loeb B550, 1125 Colonel By Drive, Ottawa, Ontario, Canada.
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Sherer SA, Meyerhoefer CD, Sheinberg M, Levick D. Integrating commercial ambulatory electronic health records with hospital systems: An evolutionary process. Int J Med Inform 2015; 84:683-93. [DOI: 10.1016/j.ijmedinf.2015.05.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/15/2015] [Accepted: 05/18/2015] [Indexed: 11/17/2022]
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Britton JR. Healthcare Reimbursement and Quality Improvement: Integration Using the Electronic Medical Record Comment on "Fee-for-Service Payment--an Evil Practice That Must Be Stamped Out?". Int J Health Policy Manag 2015; 4:549-51. [PMID: 26340397 DOI: 10.15171/ijhpm.2015.93] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 05/02/2015] [Indexed: 11/09/2022] Open
Abstract
Reimbursement for healthcare has utilized a variety of payment mechanisms with varying degrees of effectiveness. Whether these mechanisms are used singly or in combination, it is imperative that the resulting systems remunerate on the basis of the quantity, complexity, and quality of care provided. Expanding the role of the electronic medical record (EMR) to monitor provider practice, patient responsiveness, and functioning of the healthcare organization has the potential to not only enhance the accuracy and efficiency of reimbursement mechanisms but also to improve the quality of medical care.
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