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Musser JA, Cho J, Cohn A, Niziol LM, Ballouz D, Burke DT, Newman-Casey PA. Measuring impact of a quality improvement initiative on glaucoma clinic flow using an automated real-time locating system. BMC Ophthalmol 2022; 22:283. [PMID: 35764976 PMCID: PMC9238160 DOI: 10.1186/s12886-022-02495-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/17/2022] [Indexed: 11/30/2022] Open
Abstract
Background Lean methodology helps maximize value by reducing waste, first by defining what value and waste are in a system. In ophthalmology clinics, value is determined by the number of patients flowing through the clinic for a given time. We aimed to increase value using a lean-methodology guided policy change, then assessed its impact on clinic flow using an automated radiofrequency identification (RFID) based real-time locating system (RTLS). Methods A total of 6813 clinical visits occurred at a single academic institution’s outpatient glaucoma clinic between January 5, 2018 to July 3, 2018. Over that period, 1589 patients comprising 1972 (29%) of visits were enrolled, with 1031 clinical visits occurring before and 941 visits after a policy change. The original policy was to refract all patients that improved with pinhole testing. The policy change was not to refract patients with a visual acuity ≥20/30 unless a specific request was made by the patient. Pre-post analysis of an automated time-motion study was conducted for the data collected 3 months before and 3 months after the policy change occurred on March 30, 2018. Changes to process and wait times were summarized using descriptive statistics and fitted to linear mixed regression models adjusting for appointment type, clinic volume, and daily clinic trends. Results One thousand nine hundred twenty-three visits with 1588 patients were included in the analysis. Mean [SD] age was 65.9 [14.7] years and 892 [56.2%] were women. After the policy change, technician process time decreased by 2.9 min (p < 0.0001) while daily clinical patient volume increased from 51.9 ± 16.8 patients to 58.4 ± 17.4 patients (p < 0.038). No significant difference was found in total wait time (p = 0.18) or total visit time (p = 0.83). Conclusions Real-time locating systems are effective at capturing clinical flow data and assessing clinical practice change initiatives. The refraction policy change was associated with reduced technician process time and overall the clinic was able to care for 7 more patients per day without significantly increasing patient wait time.
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Karat AS, McCreesh N, Baisley K, Govender I, Kallon II, Kielmann K, MacGregor H, Vassall A, Yates TA, Grant AD. Estimating waiting times, patient flow, and waiting room occupancy density as part of tuberculosis infection prevention and control research in South African primary health care clinics. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000684. [PMID: 36962412 PMCID: PMC10021248 DOI: 10.1371/journal.pgph.0000684] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 06/13/2022] [Indexed: 01/13/2023]
Abstract
Transmission of respiratory pathogens, such as Mycobacterium tuberculosis and severe acute respiratory syndrome coronavirus 2, is more likely during close, prolonged contact and when sharing a poorly ventilated space. Reducing overcrowding of health facilities is a recognised infection prevention and control (IPC) strategy; reliable estimates of waiting times and 'patient flow' would help guide implementation. As part of the Umoya omuhle study, we aimed to estimate clinic visit duration, time spent indoors versus outdoors, and occupancy density of waiting rooms in clinics in KwaZulu-Natal (KZN) and Western Cape (WC), South Africa. We used unique barcodes to track attendees' movements in 11 clinics, multiple imputation to estimate missing arrival and departure times, and mixed-effects linear regression to examine associations with visit duration. 2,903 attendees were included. Median visit duration was 2 hours 36 minutes (interquartile range [IQR] 01:36-3:43). Longer mean visit times were associated with being female (13.5 minutes longer than males; p<0.001) and attending with a baby (18.8 minutes longer than those without; p<0.01), and shorter mean times with later arrival (14.9 minutes shorter per hour after 0700; p<0.001). Overall, attendees spent more of their time indoors (median 95.6% [IQR 46-100]) than outdoors (2.5% [IQR 0-35]). Attendees at clinics with outdoor waiting areas spent a greater proportion (median 13.7% [IQR 1-75]) of their time outdoors. In two clinics in KZN (no appointment system), occupancy densities of ~2.0 persons/m2 were observed in smaller waiting rooms during busy periods. In one clinic in WC (appointment system, larger waiting areas), occupancy density did not exceed 1.0 persons/m2 despite higher overall attendance. In this study, longer waiting times were associated with early arrival, being female, and attending with a young child. Occupancy of waiting rooms varied substantially between rooms and over the clinic day. Light-touch estimation of occupancy density may help guide interventions to improve patient flow.
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Affiliation(s)
- Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- The Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| | - Nicky McCreesh
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kathy Baisley
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Africa Health Research Institute, School of Laboratory Medicine & Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Indira Govender
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Idriss I Kallon
- Division of Social and Behavioural Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karina Kielmann
- The Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| | - Hayley MacGregor
- The Institute of Development Studies, University of Sussex, Brighton, United Kingdom
| | - Anna Vassall
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tom A Yates
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Africa Health Research Institute, School of Laboratory Medicine & Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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SUCCESSFUL INTERVENTIONS TO IMPROVE EFFICIENCY AND REDUCE PATIENT VISIT DURATION IN A RETINA PRACTICE. Retina 2021; 41:2157-2162. [PMID: 33758134 PMCID: PMC8448795 DOI: 10.1097/iae.0000000000003169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To reduce the total clinic visit duration among retina providers in an academic ophthalmology department. METHODS All patient encounters across all providers in the department were analyzed to determine baseline clinic visit duration time, defined as the elapsed time between appointment time and checkout. To increase photography capacity, a major bottleneck identified through root cause analysis, four interventions were implemented: training ophthalmic technicians to perform fundus photography in addition to optical coherence tomographies, relocating photography equipment to be adjacent to examination rooms, procuring three additional Optos widefield retinal photography units, and shifting staff schedules to better align with that of the providers. These interventions were implemented in the clinics of two retina providers. RESULTS The average baseline visit duration for all patients across all providers was 87 minutes (19,550 patient visits). The previous average visit duration was 80 minutes for Provider 1 (557 patient visits) and 81 minutes for Provider 2 (1,246 patient visits). In the 4 weeks after interventions were implemented, the average visit duration decreased to 60 minutes for Provider 1 and 57 minutes for Provider 2. CONCLUSION A systematic approach and a multidisciplinary team resulted in targeted, cost-effective interventions that reduced total visit durations.
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Singman EL, Smith K, Mehta R, Boland MV, Srikumaran D, Frick K, Young L, Locco G, Tian J, Kowalewski C, McDonnell P. Cost and Visit Duration of Same-Day Access at an Academic Ophthalmology Department vs Emergency Department. JAMA Ophthalmol 2020; 137:729-735. [PMID: 31021382 DOI: 10.1001/jamaophthalmol.2019.0864] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Convenient outpatient access for ophthalmology patients seeking urgent care could offer savings compared with an emergency department (ED) visit. Objective To evaluate the costs and visit durations of same-day access (SDA) in an ophthalmology department at an academic medical center vs ED care. Design, Setting, and Participants This single-center study was a retrospective quality improvement analysis of an institutional electronic medical record system at the Wilmer Eye Institute clinics and the Johns Hopkins Hospital ED. On June 1, 2015, the Wilmer Eye Institute and Johns Hopkins Hospital initiated an official policy of providing SDA to patients calling for appointments (ie, the same-day project). All ophthalmology clinic locations created same-day appointment slots for at least 1 practitioner. In recognition of seasonal variations in patient visit volumes, the 10 months before implementation (August 1, 2014, to May 31, 2015) were compared with complementary periods in 2015 to 2016 and 2016 to 2017. Main Outcomes and Measures The study tabulated encounters, charges, and visit length for outpatients seen on the same day or by previously scheduled appointments. For the ED patients, volume, diagnoses, charges, and length of stay data were collected. The numbers of SDA patients who indicated urgency were tabulated. Results The number of SDA patients increased from 22 781 to 26 579 for the first year after SDA implementation. The mean charge was $258 (95% CI, $250-$266; median, $184; interquartile range [IQR], $175-$320), and the mean clinic transit time was 1.55 hours (95% CI, 1.54-1.57 hours; median, 1.28 hours). For patients seeking eye care in the ED, the mean professional fee was $401 (95% CI, $390-$411; median, $360; IQR, $255-$500), the mean (SD) total hospital charge was $1040 ($999) (95% CI, $729-$1079; median, $1002; IQR, $334-$1429), and the mean length of stay was 7.30 hours (95% CI, 7.01-7.57 hours; median, 7.20 hours). The top 4 ophthalmic diagnoses for ED patients were conjunctivitis, cornea abrasion, iritis, and visual loss, which were unchanged after SDA implementation. In calendar year 2017, a total of 4062 SDA patients reported urgency; their estimated savings in charges compared with an ED visit were $580 866 in professional fees and $3 176 484 in hospital charges. Conclusions and Relevance Same-day access appears to be less expensive and to require less time in the health care system than a visit to the ED for an ophthalmic diagnosis. Substantial savings in time and money might be achieved if urgent eye care is delivered in the clinic rather than the ED.
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Affiliation(s)
- Eric L Singman
- Wilmer General Eye Services, The Johns Hopkins Hospital, Baltimore, Maryland.,Wilmer Eye Institute, Baltimore, Maryland
| | - Kerry Smith
- Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Radhika Mehta
- Administrations Department, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael V Boland
- Division of Health Sciences Informatics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Divya Srikumaran
- Wilmer Eye Institute, Baltimore, Maryland.,Wilmer Eye Institute at Odenton, Odenton, Maryland
| | - Kevin Frick
- Department of Health Policy and Management, Johns Hopkins Carey Business School, Baltimore, Maryland
| | | | - Gina Locco
- Ophthalmology Registration, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jing Tian
- Biostatistics Consulting Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Affiliation(s)
- Sean P Donahue
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul Sternberg
- Vanderbilt Eye Institute, Vanderbilt Medical Group, Vanderbilt School of Medicine, Nashville, Tennessee
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Sommer AC, Blumenthal EZ. Implementation of Lean and Six Sigma principles in ophthalmology for improving quality of care and patient flow. Surv Ophthalmol 2019; 64:720-728. [PMID: 30951728 DOI: 10.1016/j.survophthal.2019.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 03/21/2019] [Accepted: 03/25/2019] [Indexed: 10/27/2022]
Abstract
Lean management is a set of principles aimed at improving processes by identifying and eliminating steps that do not add value to the consumer. Such steps lead to wasted time, resources, and expenses and result in customer and employee dissatisfaction. Although initially invented and perfected for factory assembly lines in the automobile industry, it has since disseminated extensively and has repeatedly proven a powerful "engine" for improving quality and quantity in the health-care setting. Lean implementation benefits include improved safety, reduced waiting times, increased patient satisfaction, and cost reduction. Nevertheless, it appears to be less familiar and appreciated in ophthalmology and more specifically as a tool for managing an efficient eye care clinic. In this review, we explain what "Lean" and Six Sigma are and highlight their implementation in settings such as cataract surgery, laser capsulotomy, an ophthalmic emergency room and its role as a powerful tool for improving clinic patient flow. We discuss basic principles of Lean management, review examples of implementing these principles in an ophthalmology practice, and finally, offer physicians practical tools for identifying "wasteful" processes and ways to eliminate them.
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Affiliation(s)
- Adir C Sommer
- Department of Ophthalmology, Rambam Health Care Campus, Haifa, Israel
| | - Eytan Z Blumenthal
- Department of Ophthalmology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
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King K, Quarles J, Ravi V, Chowdhury TI, Friday D, Sisson C, Feng Y. The Impact of a Location-Sensing Electronic Health Record on Clinician Efficiency and Accuracy: A Pilot Simulation Study. Appl Clin Inform 2018; 9:841-848. [PMID: 30463095 DOI: 10.1055/s-0038-1675812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Through the Health Information Technology for Economic and Clinical Health Act of 2009, the federal government invested $26 billion in electronic health records (EHRs) to improve physician performance and patient safety; however, these systems have not met expectations. One of the cited issues with EHRs is the human-computer interaction, as exhibited by the excessive number of interactions with the interface, which reduces clinician efficiency. In contrast, real-time location systems (RTLS)-technologies that can track the location of people and objects-have been shown to increase clinician efficiency. RTLS can improve patient flow in part through the optimization of patient verification activities. However, the data collected by RTLS have not been effectively applied to optimize interaction with EHR systems. OBJECTIVES We conducted a pilot study with the intention of improving the human-computer interaction of EHR systems by incorporating a RTLS. The aim of this study is to determine the impact of RTLS on process metrics (i.e., provider time, number of rooms searched to find a patient, and the number of interactions with the computer interface), and the outcome metric of patient identification accuracy METHODS: A pilot study was conducted in a simulated emergency department using a locally developed camera-based RTLS-equipped EHR that detected the proximity of subjects to simulated patients and displayed patient information when subjects entered the exam rooms. Ten volunteers participated in 10 patient encounters with the RTLS activated (RTLS-A) and then deactivated (RTLS-D). Each volunteer was monitored and actions recorded by trained observers. We sought a 50% improvement in time to locate patients, number of rooms searched to locate patients, and the number of mouse clicks necessary to perform those tasks. RESULTS The time required to locate patients (RTLS-A = 11.9 ± 2.0 seconds vs. RTLS-D = 36.0 ± 5.7 seconds, p < 0.001), rooms searched to find patient (RTLS-A = 1.0 ± 1.06 vs. RTLS-D = 3.8 ± 0.5, p < 0.001), and number of clicks to access patient data (RTLS-A = 1.0 ± 0.06 vs. RTLS-D = 4.1 ± 0.13, p < 0.001) were significantly reduced with RTLS-A relative to RTLS-D. There was no significant difference between RTLS-A and RTLS-D for patient identification accuracy. CONCLUSION This pilot demonstrated in simulation that an EHR equipped with real-time location services improved performance in locating patients and reduced error compared with an EHR without RTLS. Furthermore, RTLS decreased the number of mouse clicks required to access information. This study suggests EHRs equipped with real-time location services that automates patient location and other repetitive tasks may improve physician efficiency, and ultimately, patient safety.
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Affiliation(s)
- Kevin King
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - John Quarles
- Department of Computer Science, University of Texas at San Antonio, San Antonio, Texas, United States
| | - Vaishnavi Ravi
- Department of Computer Science, University of Texas at San Antonio, San Antonio, Texas, United States
| | - Tanvir Irfan Chowdhury
- Department of Computer Science, University of Texas at San Antonio, San Antonio, Texas, United States
| | - Donia Friday
- Department of Pediatrics, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, United States
| | - Craig Sisson
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Yusheng Feng
- Department of Mechanical Engineering, University of Texas at San Antonio, San Antonio, Texas, United States
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Singman EL, Srikumaran D, Green L, Tian J, McDonnell P. Supervision and autonomy of ophthalmology residents in the outpatient Clinic in the United States: a survey of ACGME-accredited programs. BMC MEDICAL EDUCATION 2017; 17:105. [PMID: 28651531 PMCID: PMC5485577 DOI: 10.1186/s12909-017-0941-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 06/13/2017] [Indexed: 06/09/2023]
Abstract
BACKGROUND The development and demonstration of incremental trainee autonomy is required by the ACGME. However, there is scant published research concerning autonomy of ophthalmology residents in the outpatient clinic setting. This study explored the landscape of resident ophthalmology outpatient clinics in the United States. METHODS A link to an online survey using the QualtricsTM platform was emailed to the program directors of all 115 ACGME-accredited ophthalmology programs in the United States. Survey questions explored whether resident training programs hosted a continuity clinic where residents would see their own patients, and if so, the degree of faculty supervision provided therein. Metrics such as size of the resident program, number of faculty and clinic setting were also recorded. Correlations between the degree of faculty supervision and other metrics were explored. RESULTS The response rate was 94%; 69% of respondents indicated that their trainees hosted continuity clinics. Of those programs, 30% required a faculty member to see each patient treated by a resident, while 42% expected the faculty member to at least discuss (if not see) each patient. All programs expected some degree of faculty interaction based upon circumstances such as the level of training of the resident or complexity of the clinical situation. 67% of programs that tracked the contribution of the clinic to resident surgical caseloads reported that these clinics provided more than half of the resident surgical volumes. More ¾ of resident clinics were located in urban settings. The degree of faculty supervision did not correlate to any of the other metrics evaluated. CONCLUSIONS The majority of ophthalmology resident training programs in the United States host a continuity clinic located in an urban environment where residents follow their own patients. Furthermore, most of these clinics require supervising faculty to review both the patients seen and the medical documentation created by the resident encounters. The different degrees of faculty supervision outlined by this survey might provide a useful guide presuming they can be correlated with validated metrics of educational quality. Finally, this study could provide an adjunctive resource to current international efforts to standardize ophthalmic residency education.
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Affiliation(s)
- Eric L. Singman
- Wilmer Eye Institute General Eye Services Clinic, @ Johns Hopkins Hospital, Wilmer B-29, 600 N. Wolfe St, Baltimore, MD 21287 USA
| | - Divya Srikumaran
- Wilmer Eye Institute General Eye Services Clinic, @ Johns Hopkins Hospital, Wilmer B-29, 600 N. Wolfe St, Baltimore, MD 21287 USA
| | - Laura Green
- Ophthalmology Residency Program Director, Lifebridge Health Krieger Eye Institute, 2411 W. Belvedere Ave, Baltimore, MD 21215 USA
| | - Jing Tian
- Biostatistics Consulting Center, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe St, Room 3148, Baltimore, MD 21287 USA
| | - Peter McDonnell
- Wilmer Eye Institute, @ Johns Hopkins Hospital, Maumenee 727, 600 N. Wolfe St, Baltimore, MD 21287 USA
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Yen PY, Lara B, Lopetegui M, Bharat A, Ardoin S, Johnson B, Mathur P, Embi PJ, Curtis JR. Usability and Workflow Evaluation of "RhEumAtic Disease activitY" (READY). A Mobile Application for Rheumatology Patients and Providers. Appl Clin Inform 2016; 7:1007-1024. [PMID: 27803949 DOI: 10.4338/aci-2016-03-ra-0036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 09/19/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND RhEumAtic Disease activitY (READY) is a mobile health (mHealth) application that aims to create a shared platform integrating data from both patients and physicians, with a particular emphasis on arthritis disease activity. METHODS We made READY available on an iPad and pilot implemented it at a rheumatology outpatient clinic. We conducted 1) a usability evaluation study to explore patients' and physicians' interactions with READY, and 2) a time motion study (TMS) to observe the clinical workflow before and after the implementation. RESULTS A total of 33 patients and 15 physicians participated in the usability evaluation. We found usability problems in navigation, data entry, pain assessment, documentation, and instructions along with error messages. Despite these issues, 25 (75,76%) patients reported they liked READY. Physicians provided mixed feedback because they were concerned about the impact of READY on clinical workflow. Six physicians participated in the TMS. We observed 47 patient visits (44.72 hours) in the pre-implementation phase, and 42 patient visits (37.82 hours) in the post-implementation phase. We found that patients spent more time on READY than paper (4.39mins vs. 2.26mins), but overall, READY did not delay the workflow (pre = 52.08 mins vs. post = 45.46 mins). This time difference may be compensated with READY eliminating a workflow step for the staff. CONCLUSION Patients preferred READY to paper documents. Many found it easier to input information because of the larger font size and the ease of 'tapping' rather than writing-out or circling answers. Even though patients spent more time on READY than using paper documents, the longer usage of READY was mainly due to when troubleshooting was needed. Most patients did not have problems after receiving initial support from the staff. This study not only enabled improvements to the software but also serves as good reference for other researchers or institutional decision makers who are interested in implementing such a technology.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jeffrey R Curtis
- Jeffrey R. Curtis, MD, MS, MPH, University of Alabama at Birmingham, Division of Clinical Immunology and Rheumatology, 510 20th Street South, FOT 802D Birmingham AL 35294, Tel. 205-975-2176, E-mail:
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A personalized mobile patient guide system for a patient-centered smart hospital: Lessons learned from a usability test and satisfaction survey in a tertiary university hospital. Int J Med Inform 2016; 91:20-30. [DOI: 10.1016/j.ijmedinf.2016.04.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/20/2016] [Accepted: 04/03/2016] [Indexed: 11/21/2022]
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