Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs

Factors impacting clinical data and documentation quality in Australian aged care and disability services: a user-centred perspective

BACKGROUND

Research has highlighted a need to improve the quality of clinical documentation and data within aged care and disability services in Australia to support improved regulatory reporting and ensure quality and safety of services. However, the specific causes of data quality issues within aged care and disability services and solutions for optimisation are not well understood.

OBJECTIVES

This study explored aged care and disability workforce (referred to as 'data-users') experiences and perceived root causes of clinical data quality issues at a large aged care and disability services provider in Western Australia, to inform optimisation solutions.

METHODS

A purposive sample of n = 135 aged care and disability staff (including community-based and residential-based) in clinical, care, administrative and/or management roles participated in semi-structured interviews and web-based surveys. Data were analysed using an inductive thematic analysis method, where themes and subthemes were derived.

RESULTS

Eight overarching causes of data and documentation quality issues were identified: (1) staff-related challenges, (2) education and training, (3) external barriers, (4) operational guidelines and procedures, (5) organisational practices and culture, (6) technological infrastructure, (7) systems design limitations, and (8) systems configuration-related challenges.

CONCLUSION

The quality of clinical data and documentation within aged care and disability services is influenced by a complex interplay of internal and external factors. Coordinated and collaborative effort is required between service providers and the wider sector to identify behavioural and technical optimisation solutions to support safe and high-quality care and improved regulatory reporting.

The NeoRoo mobile app: Initial design and prototyping of an Android-based digital health tool to support Kangaroo Mother Care in low/middle-income countries (LMICs)

Premature birth and neonatal mortality are significant global health challenges, with 15 million premature births annually and an estimated 2.5 million neonatal deaths. Approximately 90% of preterm births occur in low/middle income countries, particularly within the global regions of sub-Saharan Africa and South Asia. Neonatal hypothermia is a common and significant cause of morbidity and mortality among premature and low birth weight infants, particularly in low/middle-income countries where rates of premature delivery are high, and access to health workers, medical commodities, and other resources is limited. Kangaroo Mother Care/Skin-to-Skin care has been shown to significantly reduce the incidence of neonatal hypothermia and improve survival rates among premature infants, but there are significant barriers to its implementation, especially in low/middle-income countries (LMICs). The paper proposes the use of a multidisciplinary approach to develop an integrated mHealth solution to overcome the barriers and challenges to the implementation of Kangaroo Mother Care/Skin-to-skin care (KMC/STS) in LMICs. The innovation is an integrated mHealth platform that features a wearable biomedical device (NeoWarm) and an Android-based mobile application (NeoRoo) with customized user interfaces that are targeted specifically to parents/family stakeholders and healthcare providers, respectively. This publication describes the iterative, human-centered design and participatory development of a high-fidelity prototype of the NeoRoo mobile application. The aim of this study was to design and develop an initial ("A") version of the Android-based NeoRoo mobile app specifically to support the use case of KMC/STS in health facilities in Kenya. Key functions and features are highlighted. The proposed solution leverages the promise of digital health to overcome identified barriers and challenges to the implementation of KMC/STS in LMICs and aims to equip parents and healthcare providers of prematurely born infants with the tools and resources needed to improve the care provided to premature and low birthweight babies. It is hoped that, when implemented and scaled as part of a thoughtful, strategic, cross-disciplinary approach to reduction of global rates of neonatal mortality, NeoRoo will prove to be a useful tool within the toolkit of parents, health workers, and program implementors.

Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study

Background

For patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients' needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients' full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs.

Methods

In a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey.

Discussion

Taken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs.

Trends and Patterns of Social History Data Collection Within an Electronic Health Record

There is increased acceptance that social and behavioral determinants of health (SBDH) impact health outcomes, but electronic health records (EHRs) are not always set up to capture the full range of SBDH variables in a systematic manner. The purpose of this study was to explore rates and trends of social history (SH) data collection-1 element of SBDH-in a structured portion of an EHR within a large academic integrated delivery system. EHR data for individuals with at least 1 visit in 2017 were included in this study. Completeness rates were calculated for how often SBDH variable was assessed and documented. Logistic regressions identified factors associated with assessment rates for each variable. A total of 44,166 study patients had at least 1 SH variable present. Tobacco use and alcohol use were the most frequently captured SH variables. Black individuals were more likely to have their alcohol use assessed (odds ratio [OR] 1.21) compared with White individuals, whereas White individuals were more likely to have their "smokeless tobacco use" assessed (OR 0.92). There were also differences between insurance types. Drug use was more likely to be assessed in the Medicaid population for individuals who were single (OR 0.95) compared with the commercial population (OR 1.05). SH variable assessment is inconsistent, which makes use of EHR data difficult to gain better understanding of the impact of SBDH on health outcomes. Standards and guidelines on how and why to collect SBDH information within the EHR are needed.

Documentation and review of social determinants of health data in the EHR: measures and associated insights

OBJECTIVE

Electronic Health Records (EHRs) increasingly include designated fields to capture social determinants of health (SDOH). We developed measures to characterize their use, and use of other SDOH data types, to optimize SDOH data integration.

MATERIALS AND METHODS

We developed 3 measures that accommodate different EHR data types on an encounter or patient-year basis. We implemented these measures-documented during encounter (DDE) captures documentation occurring during the encounter; documented by discharge (DBD) includes DDE plus documentation occurring any time prior to admission; and reviewed during encounter (RDE) captures whether anyone reviewed documented data-for the newly available structured SDOH fields and 4 other comparator SDOH data types (problem list, inpatient nursing question, social history free text, and social work notes) on a hospital encounter basis (with patient-year metrics in the Supplementary Appendix). Our sample included all patients (n = 27 127) with at least one hospitalization at UCSF Health (a large, urban, tertiary medical center) over a 1-year period.

RESULTS

We observed substantial variation in the use of different SDOH EHR data types. Notably, social history question fields (newly added at study period start) were rarely used (DDE: 0.03% of encounters, DBD: 0.26%, RDE: 0.03%). Free-text patient social history fields had higher use (DDE: 12.1%, DBD: 49.0%, RDE: 14.4%).

DISCUSSION

Our measures of real-world SDOH data use can guide current efforts to capture and leverage these data. For our institution, measures revealed substantial variation across data types, suggesting the need to engage in efforts such as EHR-user education and targeted workflow integration.

CONCLUSION

Measures revealed opportunities to optimize SDOH data documentation and review.

Human Factors and Organizational Issues in Health Informatics: Innovations and Opportunities

OBJECTIVE

Human factors and ergonomics (HF/E) frameworks and methods are becoming embedded in the health informatics community. There is now broad recognition that health informatics tools must account for the diverse needs, characteristics, and abilities of end users, as well as their context of use. The objective of this review is to synthesize the current nature and scope of HF/E integration into the health informatics community.

METHODS

Because the focus of this synthesis is on understanding the current integration of the HF/E and health informatics research communities, we manually reviewed all manuscripts published in primary HF/E and health informatics journals during 2020.

RESULTS

HF/E-focused health informatics studies included in this synthesis focused heavily on EHR customizations, specifically clinical decision support customizations and customized data displays, and on mobile health innovations. While HF/E methods aimed to jointly improve end user safety, performance, and satisfaction, most HF/E-focused health informatics studies measured only end user satisfaction.

CONCLUSION

HF/E-focused health informatics researchers need to identify and communicate methodological standards specific to health informatics, to better synthesize findings across resource intensive HF/E-focused health informatics studies. Important gaps in the HF/E design and evaluation process should be addressed in future work, including support for technology development platforms and training programs so that health informatics designers are as diverse as end users.

A roadmap for cardiovascular care after release from incarceration: uses of a smartphone application

OBJECTIVE

Cardiovascular disease (CVD) and its risk factors disproportionately affect people returning from incarceration. These individuals face multiple barriers to obtaining care, which can impact CVD and risk factor management and may be mitigated through use of a smartphone application (app). Therefore, we explored the CVD-related needs of people released from incarceration and which app features would support these needs.

MATERIALS AND METHODS

In 2019, we collected qualitative data through 7 focus groups with 76 returning citizens and 19 key informants through interviews and small group discussions in Baltimore, Maryland. Verbal data were audio-recorded, transcribed, and analyzed using inductive thematic coding with N-Vivo qualitative software.

RESULTS

Returning citizens face multiple barriers when trying to engage in care and services related to cardiovascular health, including around medications and health insurance. Some major challenges were identifying trusted social services and making cardiovascular health a priority. Findings suggested that CVD risk factors could be more effectively addressed in combination with attending to other pressing needs related to employment, housing, behavioral health, and building trust. Participants suggested that a smartphone app would be most useful if it broadly addressed these issues by linking returning citizens to social services, including recommendations from peers, and facilitating access to healthcare.

DISCUSSION

Returning citizens need broad support for societal reintegration. Addressing social issues would allow them to focus on cardiovascular health.

CONCLUSION

Given the challenges experienced after release from incarceration, an app focused on social and health-access issues may help returning citizens meet their CVD needs.

The Envirome Web Service: Patient context at the point of care

Patient context - the "envirome" - can have a significant impact on patient health. While envirome indicators are available through large scale public data sources, they are not provided in a format that can be easily accessed and interpreted at the point of care by healthcare providers with limited time during a patient encounter. We developed a clinical decision support tool to bring envirome indicators to the point of care in a large pediatric hospital system in the Kansas City region. The Envirome Web Service (EWS) securely geocodes patient addresses in real time to link their records with publicly available context data. End-users guided the design of the EWS, which presents summaries of patient context data in the electronic health record (EHR) without disrupting the provider workflow. Through surveys, focus groups, and a formal review by hospital staff, the EWS was deployed into production use, integrating publicly available data on food access with the hospital EHR. Evaluation of EWS usage during the 2020 calendar year shows that 1,034 providers viewed the EWS, with a total of 29,165 sessions. This suggests that the EWS was successfully integrated with the EHR and is highly visible. The results also indicate that 63 (6.1%) of the providers are regular users that opt to maintain the EWS in their custom workflows, logging more than 100 EWS sessions during the year. The vendor agnostic design of the EWS supports interoperability and makes it accessible to health systems with disparate EHR vendors.

Agile Innovation to transform healthcare: innovating in complex adaptive systems is an everyday process, not a light bulb event

Innovation is essential to transform healthcare delivery systems, but in complex adaptive systems innovation is more than ‘light bulb events’ of inspired creativity. To achieve true innovation, organisations must adopt a disciplined, customer-centred process. We developed the process of Agile Innovation as an approach any complex adaptive organisation can adopt to achieve rapid, systematic, customer-centred development and testing of innovative interventions. Agile Innovation incorporates insights from design thinking, Agile project management, and complexity and behavioural sciences. It was refined through experiments in diverse healthcare organisations. The eight steps of Agile Innovation are: (1) confirm demand; (2) study the problem; (3) scan for solutions; (4) plan for evaluation and termination; (5) ideate and select; (6) run innovation development sprints; (7) validate solutions; and (8) package for launch. In addition to describing each of these steps, we discuss examples of and challenges to using Agile Innovation. We contend that once Agile Innovation is mastered, healthcare delivery organisations can habituate it as the go-to approach to projects, thus incorporating innovation into how things are done, rather than treating innovation as a light bulb event.

Uncovering the Value of a Historical Paper-Based Collaborative Artifact: The Nursing Unit's Kardex System

We identify useful functions and usability characteristics of a historical cognitive artifact used by nurses working in a hospital unit, the Kardex. By identifying aspects of a widely used artifact, we uncover opportunities to improve the usefulness of current systems for hospital nurses. We conducted semi-structured interviews with registered nurses about their prior experience with the Kardex. Questions included what elements of the Kardex are missing from their current electronic support. Memos were generated iteratively from interview transcript data and grouped into themes. Eighteen nurses from multiple clinical areas participated and had a median of 25–29 years of nursing experience. The themes were: (1) a status at a glance summary for each patient, (2) a prospective memory aid, (3) efficiency and ease of use, (4) updating information required to maintain value, (5) activity management, (6) verbal handover during shift-to-shift report, (7) narrative charting and personalized care, and (8) non-clinical care communication. Implications for digital support are to provide immediate, portable access to a standardized patient summary, support for nurses to manage their planned activities during a series of shifts, provide unstructured text fields for narrative charting, and to support adding informal notes for personalized care.