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Ward MJ, Matheny ME, Rubenstein MD, Bonnet K, Dagostino C, Schlundt DG, Anders S, Reese T, Mixon AS. Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration. BMC Health Serv Res 2024; 24:640. [PMID: 38760660 PMCID: PMC11102113 DOI: 10.1186/s12913-024-11082-0] [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: 10/11/2023] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration. METHODS We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process. RESULTS We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal. CONCLUSIONS The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.
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Affiliation(s)
- Michael J Ward
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA.
- Medicine Service, Tennessee Valley Healthcare System, Nashville, TN, USA.
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Michael E Matheny
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa D Rubenstein
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Chloe Dagostino
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Shilo Anders
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Duckro AN, Mueller SR, Kraus CR, Steiner CA, Steiner JF. Developing Patient-Centered Communication Ecosystems in Integrated Health Care Delivery Organizations. Perm J 2023; 27:116-120. [PMID: 37737659 PMCID: PMC10723088 DOI: 10.7812/tpp/23.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Affiliation(s)
- Amy N Duckro
- Departments of Infectious Diseases and Population Management, Colorado Permanente Medical Group, Denver, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
| | - Shane R Mueller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Courtney R Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Claudia A Steiner
- Colorado Permanente Medical Group, Denver, CO, USA
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - John F Steiner
- Colorado Permanente Medical Group, Denver, CO, USA
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Ghazi L, Yamamoto Y, Fuery M, O'Connor K, Sen S, Samsky M, Riello RJ, Dhar R, Huang J, Olufade T, McDermott J, Inzucchi SE, Velazquez EJ, Wilson FP, Desai NR, Ahmad T. Electronic health record alerts for management of heart failure with reduced ejection fraction in hospitalized patients: the PROMPT-AHF trial. Eur Heart J 2023; 44:4233-4242. [PMID: 37650264 DOI: 10.1093/eurheartj/ehad512] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND AND AIMS Patients hospitalized for acute heart failure (AHF) continue to be discharged on an inadequate number of guideline-directed medical therapies (GDMT) despite evidence that inpatient initiation is beneficial. This study aimed to examine whether a tailored electronic health record (EHR) alert increased rates of GDMT prescription at discharge in eligible patients hospitalized for AHF. METHODS Pragmatic trial of messaging to providers about treatment of acute heart failure (PROMPT-AHF) was a pragmatic, multicenter, EHR-based, and randomized clinical trial. Patients were automatically enrolled 48 h after admission if they met pre-specified criteria for an AHF hospitalization. Providers of patients in the intervention arm received an alert during order entry with relevant patient characteristics along with individualized GDMT recommendations with links to an order set. The primary outcome was an increase in the number of GDMT prescriptions at discharge. RESULTS Thousand and twelve patients were enrolled between May 2021 and November 2022. The median age was 74 years; 26% were female, and 24% were Black. At the time of the alert, 85% of patients were on β-blockers, 55% on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, 20% on mineralocorticoid receptor antagonist (MRA) and 17% on sodium-glucose cotransporter 2 inhibitor. The primary outcome occurred in 34% of both the alert and no alert groups [adjusted risk ratio (RR): 0.95 (0.81, 1.12), P = .99]. Patients randomized to the alert arm were more likely to have an increase in MRA [adjusted RR: 1.54 (1.10, 2.16), P = .01]. At the time of discharge, 11.2% of patients were on all four pillars of GDMT. CONCLUSIONS A real-time, targeted, and tailored EHR-based alert system for AHF did not lead to a higher number of overall GDMT prescriptions at discharge. Further refinement and improvement of such alerts and changes to clinician incentives are needed to overcome barriers to the implementation of GDMT during hospitalizations for AHF. GDMT remains suboptimal in this setting, with only one in nine patients being discharged on a comprehensive evidence-based regimen for heart failure.
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Affiliation(s)
- Lama Ghazi
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Michael Fuery
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Kyle O'Connor
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Marc Samsky
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Ravi Dhar
- Center for Customer Insights, Yale School of Management, New Haven, CT, USA
| | | | | | | | - Silvio E Inzucchi
- Section of Endocrine & Metabolism, Yale School of Medicine, New Haven, CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Francis Perry Wilson
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Nihar R Desai
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Tariq Ahmad
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
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Gross ME, Godecker A, Hughes A, Sampene K. Leveraging quality improvement to promote health equity: standardization of prenatal aspirin recommendations. BMC Pregnancy Childbirth 2023; 23:651. [PMID: 37684606 PMCID: PMC10492279 DOI: 10.1186/s12884-023-05922-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE Aspirin (ASA) is recommended for patients at elevated risk of preeclampsia. Limited data exists on adherence to guidelines for ASA prescription. This project evaluates the implementation of a standardized approach to ASA prescription in an academic OB/Gyn practice. METHODS We implemented a quality improvement project to evaluate compliance with the United States Preventative Services Task Force (USPSTF) recommendations for ASA to prevent preeclampsia. Pre-intervention, we analyzed prescription adherence at 201 New Obstetric (NOB) visits. A multi-step intervention was then implemented at 199 NOB visits. Nurses utilized a checklist created from USPSTF guidelines to identify high-risk patients, defined as having ≥1 high-risk factor or ≥2 moderate-risk factors. ASA orders were placed by physicians. A Plan-Do-Study-Act (PDSA) cycle was performed, and changes implemented. Primary outcome was percent of patients screened at RN intake visit (goal = 90%). Secondary outcomes were percent of patients who screened positive that received the ASA recommendation (goal = 80%) and percent screened and recommended by race. RESULTS Pre-intervention, 47% of patients met criteria for ASA and 28% received a documented recommendation. Post-intervention, 99% were screened. Half (48%) met criteria for an ASA recommendation and 79% received a recommendation (p = < 0.001). Rates of appropriate recommendation did not differ by Black (80%) vs. non-Black (79%) status (p = 0.25). Subsequent PDSA cycles for 12 months neared 100% RN screening rates. Physicians correctly recommended ASA 80-100% of the time. CONCLUSION It is feasible, sustainable and equitable to standardize screening and implementation of ASA to patients at high risk for preeclampsia. Providers can easily reproduce our processes to improve delivery of equitable and reliable preventative obstetric care.
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Affiliation(s)
- Maya E Gross
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Amy Godecker
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ainsley Hughes
- Department of Obstetrics and Gynecology, George Washington School of Medicine, Washington, DC, USA
| | - Katherine Sampene
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Arnold M, Goldschmitt M, Rigotti T. Dealing with information overload: a comprehensive review. Front Psychol 2023; 14:1122200. [PMID: 37416535 PMCID: PMC10322198 DOI: 10.3389/fpsyg.2023.1122200] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/26/2023] [Indexed: 07/08/2023] Open
Abstract
Information overload is a problem that is being exacerbated by the ongoing digitalization of the world of work and the growing use of information and communication technologies. Therefore, the aim of this systematic literature review is to provide an insight into existing measures for prevention and intervention related to information overload. The methodological approach of the systematic review is based on the PRISMA standards. A keyword search in three interdisciplinary scientific databases and other more practice-oriented databases resulted in the identification of 87 studies, field reports, and conceptual papers that were included in the review. The results show that a considerable number of papers have been published on interventions on the behavioral prevention level. At the level of structural prevention, there are also many proposals on how to design work to reduce information overload. A further distinction can be made between work design approaches at the level of information and communication technology and at the level of teamwork and organizational regulations. Although the identified studies cover a wide range of possible interventions and design approaches to address information overload, the strength of the evidence from these studies is mixed.
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Affiliation(s)
- Miriam Arnold
- Leibniz Institute for Resilience Research, Mainz, Germany
| | | | - Thomas Rigotti
- Leibniz Institute for Resilience Research, Mainz, Germany
- Work, Organizational and Business Psychology, Johannes Gutenberg-University Mainz, Mainz, Germany
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Samal L, Wu E, Aaron S, Kilgallon JL, Gannon M, McCoy A, Blecker S, Dykes PC, Bates DW, Lipsitz S, Wright A. Refining Clinical Phenotypes to Improve Clinical Decision Support and Reduce Alert Fatigue: A Feasibility Study. Appl Clin Inform 2023; 14:528-537. [PMID: 37437601 PMCID: PMC10338104 DOI: 10.1055/s-0043-1768994] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 04/18/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is common and associated with adverse clinical outcomes. Most care for early CKD is provided in primary care, including hypertension (HTN) management. Computerized clinical decision support (CDS) can improve the quality of care for CKD but can also cause alert fatigue for primary care physicians (PCPs). Computable phenotypes (CPs) are algorithms to identify disease populations using, for example, specific laboratory data criteria. OBJECTIVES Our objective was to determine the feasibility of implementation of CDS alerts by developing CPs and estimating potential alert burden. METHODS We utilized clinical guidelines to develop a set of five CPs for patients with stage 3 to 4 CKD, uncontrolled HTN, and indications for initiation or titration of guideline-recommended antihypertensive agents. We then conducted an iterative data analytic process consisting of database queries, data validation, and subject matter expert discussion, to make iterative changes to the CPs. We estimated the potential alert burden to make final decisions about the scope of the CDS alerts. Specifically, the number of times that each alert could fire was limited to once per patient. RESULTS In our primary care network, there were 239,339 encounters for 105,992 primary care patients between April 1, 2018 and April 1, 2019. Of these patients, 9,081 (8.6%) had stage 3 and 4 CKD. Almost half of the CKD patients, 4,191 patients, also had uncontrolled HTN. The majority of CKD patients were female, elderly, white, and English-speaking. We estimated that 5,369 alerts would fire if alerts were triggered multiple times per patient, with a mean number of alerts shown to each PCP ranging from 0.07-to 0.17 alerts per week. CONCLUSION Development of CPs and estimation of alert burden allows researchers to iteratively fine-tune CDS prior to implementation. This method of assessment can help organizations balance the tradeoff between standardization of care and alert fatigue.
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Affiliation(s)
- Lipika Samal
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Edward Wu
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Alabama College of Osteopathic Medicine, Dothan, Alabama, United States
| | - Skye Aaron
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - John L. Kilgallon
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Michael Gannon
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Eastern Virginia Medical School, Norfolk, Virginia, United States
| | - Allison McCoy
- Vanderbilt University, Nashville, Tennessee, United States
| | - Saul Blecker
- NYU School of Medicine, New York, New York, United States
| | - Patricia C. Dykes
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - David W. Bates
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Stuart Lipsitz
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Adam Wright
- Vanderbilt University, Nashville, Tennessee, United States
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Hempel S, Bolshakova M, Turner BJ, Dinalo J, Rose D, Motala A, Fu N, Clemesha CG, Rubenstein L, Stockdale S. Evidence-Based Quality Improvement: a Scoping Review of the Literature. J Gen Intern Med 2022; 37:4257-4267. [PMID: 36175760 PMCID: PMC9708973 DOI: 10.1007/s11606-022-07602-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Quality improvement (QI) initiatives often reflect approaches based on anecdotal evidence, but it is unclear how initiatives can best incorporate scientific literature and methods into the QI process. Review of studies of QI initiatives that aim to systematically incorporate evidence review (termed evidence-based quality improvement (EBQI)) may provide a basis for further methodological development. METHODS In this scoping review (registration: https://osf.io/hr5bj ) of EBQI, we searched the databases PubMed, CINAHL, and SCOPUS. The review addressed three central questions: How is EBQI defined? How is evidence used to inform evidence-informed QI initiatives? What is the effectiveness of EBQI? RESULTS We identified 211 publications meeting inclusion criteria. In total, 170 publications explicitly used the term "EBQI." Published definitions emphasized relying on evidence throughout the QI process. We reviewed a subset of 67 evaluations of QI initiatives in primary care, including both studies that used the term "EBQI" with those that described an evidence-based initiative without using EBQI terminology. The most frequently reported EBQI components included use of evidence to identify previously tested effective QI interventions; engaging stakeholders; iterative intervention development; partnering with frontline clinicians; and data-driven evaluation of the QI intervention. Effectiveness estimates were positive but varied in size in ten studies that provided data on patient health outcomes. CONCLUSIONS EBQI is a promising strategy for integrating relevant prior scientific findings and methods systematically in the QI process, from the initial developmental phase of the IQ initiative through to its evaluation. Future QI researchers and practitioners can use these findings as the basis for further development of QI initiatives.
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Affiliation(s)
- Susanne Hempel
- Southern California Evidence Review Center, University of Southern California, Los Angeles, CA, USA.,Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, CA, USA.,RAND Health, RAND Corporation, Santa Monica, CA, USA
| | - Maria Bolshakova
- Southern California Evidence Review Center, University of Southern California, Los Angeles, CA, USA
| | - Barbara J Turner
- Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, CA, USA
| | | | - Danielle Rose
- Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Aneesa Motala
- Southern California Evidence Review Center, University of Southern California, Los Angeles, CA, USA.,Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, CA, USA.,RAND Health, RAND Corporation, Santa Monica, CA, USA
| | - Ning Fu
- Southern California Evidence Review Center, University of Southern California, Los Angeles, CA, USA. .,School of Economics, Shanghai University of Finance and Economics, Shanghai, China.
| | | | | | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Abstract
BACKGROUND AND OBJECTIVE Electronic health records (EHRs) have become ubiquitous in medicine and continue to grow in informational content. Little has been documented regarding patient safety from the resultant information overload. The objective of this literature review is to better understand how information overload in EHR affects patient safety. METHODS A literature search was performed using the Transparent Reporting of Systematic Reviews and Meta-Analyses standards for literature review. PubMed and Web of Science were searched and articles selected that were relevant to EHR information overload based on keywords. RESULTS The literature search yielded 28 articles meeting the criteria for the study. Information overload was found to increase physician cognitive load and error rates in clinical simulations. Overabundance of clinically irrelevant information, poor data display, and excessive alerting were consistently identified as issues that may lead to information overload. CONCLUSIONS Information overload in EHRs may result in higher error rates and negatively impact patient safety. Further studies are necessary to define the role of EHR in adverse patient safety events and to determine methods to mitigate these errors. Changes focused on the usability of EHR should be considered with the end user (physician) in mind. Federal agencies have a role to play in encouraging faster adoption of improved EHR interfaces.
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Wagstaff D, Warnakulasuriya S, Singleton G, Moonesinghe SR, Fulop N, Vindrola-Padros C. A scoping review of local quality improvement using data from UK perioperative National Clinical Audits. Perioper Med (Lond) 2022; 11:43. [PMID: 36031654 PMCID: PMC9422140 DOI: 10.1186/s13741-022-00273-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 06/22/2022] [Indexed: 11/28/2022] Open
Abstract
Background Significant resources are invested in the UK to collect data for National Clinical Audits (NCAs), but it is unclear whether and how they facilitate local quality improvement (QI). The perioperative setting is a unique context for QI due to its multidisciplinary nature and history of measurement. It is unclear which NCAs evaluate perioperative care, to what extent their data have been used for QI, and which factors influence this usage. Methods NCAs were identified from the directories held by Healthcare Quality Improvement Partnership (HQIP), Scottish Healthcare Audits and the Welsh National Clinical Audit and Outcome Review Advisory Committee. QI reports were identified by the following: systematically searching MEDLINE, CINAHL Plus, Web of Science, Embase, Google Scholar and HMIC up to December 2019, hand-searching grey literature and consulting relevant stakeholders. We charted features describing both the NCAs and the QI reports and summarised quantitative data using descriptive statistics and qualitative themes using framework analysis. Results We identified 36 perioperative NCAs in the UK and 209 reports of local QI which used data from 19 (73%) of these NCAs. Six (17%) NCAs contributed 185 (89%) of these reports. Only one NCA had a registry of local QI projects. The QI reports were mostly brief, unstructured, often published by NCAs themselves and likely subject to significant reporting bias. Factors reported to influence local QI included the following: perceived data validity, measurement of clinical processes as well as outcomes, timely feedback, financial incentives, sharing of best practice, local improvement capabilities and time constraints of clinicians. Conclusions There is limited public reporting of UK perioperative NCA data for local QI, despite evidence of improvement of most NCA metrics at the national level. It is therefore unclear how these improvements are being made, and it is likely that opportunities are being missed to share learning between local sites. We make recommendations for how NCAs could better support the conduct, evaluation and reporting of local QI and suggest topics which future research should investigate. Trial registration The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018092993). Supplementary Information The online version contains supplementary material available at 10.1186/s13741-022-00273-0.
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Thomas E. An Interview with Hardeep Singh, MD, MPH. Jt Comm J Qual Patient Saf 2022; 48:365-369. [PMID: 35787348 DOI: 10.1016/j.jcjq.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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The effect of My Health Record use in the emergency department on clinician-assessed patient care: results from a survey. BMC Med Inform Decis Mak 2022; 22:178. [PMID: 35791028 PMCID: PMC9255536 DOI: 10.1186/s12911-022-01920-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 07/01/2022] [Indexed: 11/26/2022] Open
Abstract
Background The emergency department has been a major focus for the implementation of Australia’s national electronic health record, known as My Health Record. However, the association between use of My Health Record in the emergency department setting and patient care is largely unknown. The aim of this study was to explore the perspectives of emergency department clinicians regarding My Health Record use frequency, the benefits of My Health Record use (with a focus on patient care) and the barriers to use. Methods All 393 nursing, pharmacy, physician and allied health staff employed within the emergency department at a tertiary metropolitan public hospital in Melbourne were invited to participate in a web-based survey, between 1 May 2021 and 1 December 2021, during the height of the Delta and Omicron Covid-19 outbreaks in Victoria, Australia. Results Overall, the survey response rate was 18% (70/393). Approximately half of the sample indicated My Health Record use in the emergency department (n = 39, 56%, confidence interval [CI] 43–68%). The results showed that users typically only engaged with My Health Record less than once per shift (n = 15, 39%, CI 23–55%). Just over half (n = 19/39, 54%, CI 32–65%) of all participants who use My Health Record agreed they could remember a time when My Health Record had been critical to the care of a patient. Overall, clinicians indicated the biggest barrier preventing their use of My Health Record is that they forget to utilise the system. Conclusion The results suggest that My Health Record has not been adopted as routine practice in the emergency department, by the majority of participants. Close to half of self-identified users of My Health Record do not associate use as being critical to patient care. Instead, My Health Record may only be used in scenarios that clinicians perceive will yield the greatest benefit—which clinicians in this paper suggest is patients with chronic and complex conditions. Further research that explores the predictors to use and consumers most likely to benefit from use is recommended—and strategies to socialise this knowledge and educate clinicians is desperately required. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01920-8.
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Yin Z, Liu Y, McCoy AB, Malin BA, Sengstack PR. Contribution of Free-Text Comments to the Burden of Documentation: Assessment and Analysis of Vital Sign Comments in Flowsheets. J Med Internet Res 2021; 23:e22806. [PMID: 33661128 PMCID: PMC7974764 DOI: 10.2196/22806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/11/2020] [Accepted: 01/18/2021] [Indexed: 11/21/2022] Open
Abstract
Background Documentation burden is a common problem with modern electronic health record (EHR) systems. To reduce this burden, various recording methods (eg, voice recorders or motion sensors) have been proposed. However, these solutions are in an early prototype phase and are unlikely to transition into practice in the near future. A more pragmatic alternative is to directly modify the implementation of the existing functionalities of an EHR system. Objective This study aims to assess the nature of free-text comments entered into EHR flowsheets that supplement quantitative vital sign values and examine opportunities to simplify functionality and reduce documentation burden. Methods We evaluated 209,055 vital sign comments in flowsheets that were generated in the Epic EHR system at the Vanderbilt University Medical Center in 2018. We applied topic modeling, as well as the natural language processing Clinical Language Annotation, Modeling, and Processing software system, to extract generally discussed topics and detailed medical terms (expressed as probability distribution) to investigate the stories communicated in these comments. Results Our analysis showed that 63.33% (6053/9557) of the users who entered vital signs made at least one free-text comment in vital sign flowsheet entries. The user roles that were most likely to compose comments were registered nurse, technician, and licensed nurse. The most frequently identified topics were the notification of a result to health care providers (0.347), the context of a measurement (0.307), and an inability to obtain a vital sign (0.224). There were 4187 unique medical terms that were extracted from 46,029 (0.220) comments, including many symptom-related terms such as “pain,” “upset,” “dizziness,” “coughing,” “anxiety,” “distress,” and “fever” and drug-related terms such as “tylenol,” “anesthesia,” “cannula,” “oxygen,” “motrin,” “rituxan,” and “labetalol.” Conclusions Considering that flowsheet comments are generally not displayed or automatically pulled into any clinical notes, our findings suggest that the flowsheet comment functionality can be simplified (eg, via structured response fields instead of a text input dialog) to reduce health care provider effort. Moreover, rich and clinically important medical terms such as medications and symptoms should be explicitly recorded in clinical notes for better visibility.
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Affiliation(s)
- Zhijun Yin
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, United States
| | - Yongtai Liu
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, United States
| | - Allison B McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Bradley A Malin
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, United States.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
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Shah T, Kitts AB, Gold JA, Horvath K, Ommaya A, Frank O, Sato L, Schwarze G, Upton M, Sandy L. Electronic Health Record Optimization and Clinician Well-Being: A Potential Roadmap Toward Action. NAM Perspect 2020; 2020:202008a. [PMID: 35291737 PMCID: PMC8916811 DOI: 10.31478/202008a] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
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14
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Bradley SM, Bajpai A, Thomas C, Witt S, Rush P, Strauss CE, Eckman PM. Identifying and Addressing Gaps in the Use of Cardiac Resynchronization Therapy. J Card Fail 2020; 26:739-741. [DOI: 10.1016/j.cardfail.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/07/2020] [Accepted: 02/20/2020] [Indexed: 10/24/2022]
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15
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Thomas J, Dahm MR, Li J, Smith P, Irvine J, Westbrook JI, Georgiou A. Variation in electronic test results management and its implications for patient safety: A multisite investigation. J Am Med Inform Assoc 2020; 27:1214-1224. [PMID: 32719839 PMCID: PMC7481032 DOI: 10.1093/jamia/ocaa093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 05/06/2020] [Indexed: 11/15/2022] Open
Abstract
Objective The management and follow-up of diagnostic test results is a major patient safety concern. The aim of this qualitative study was to explore how clinicians manage test results on an everyday basis (work-as-done) in a health information technology–enabled emergency department setting. The objectives were to identify (1) variations in work-as-done in test results management and (2) the strategies clinicians use to ensure optimal management of diagnostic test results. Materials and Methods Qualitative interviews (n = 26) and field observations were conducted across 3 Australian emergency departments. Interview data coded for results management (ie, tracking, acknowledgment, and follow-up), and artifacts, were reviewed to identify variations in descriptions of work-as-done. Thematic analysis was performed to identify common themes. Results Despite using the same test result management application, there were variations in how the system was used. We identified 5 themes relating to electronic test results management: (1) tracking test results, (2) use and understanding of system functionality, (3) visibility of result actions and acknowledgment, (4) results inbox use, and (5) challenges associated with the absence of an inbox for results notifications for advanced practice nurses. Discussion Our findings highlight that variations in work-as-done can function to overcome perceived impediments to managing test results in a HIT-enabled environment and thus identify potential risks in the process. By illuminating work-as-done, we identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality. Conclusions Test results tracking and follow-up is a priority area in need of health information technology development and training to improve team-based collaboration/communication of results follow-up and diagnostic safety.
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Affiliation(s)
- Judith Thomas
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Maria R Dahm
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Julie Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Peter Smith
- Emergency Medicine, Illawarra Shoalhaven Local Health District, New South Wales, Australia.,Graduate School of Medicine, University of Wollongong, New South Wales, Australia
| | - Jacqui Irvine
- Emergency Medicine, Illawarra Shoalhaven Local Health District, New South Wales, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
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16
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Powell L, Sittig DF, Chrouser K, Singh H. Assessment of Health Information Technology-Related Outpatient Diagnostic Delays in the US Veterans Affairs Health Care System: A Qualitative Study of Aggregated Root Cause Analysis Data. JAMA Netw Open 2020; 3:e206752. [PMID: 32584406 PMCID: PMC7317596 DOI: 10.1001/jamanetworkopen.2020.6752] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Diagnostic delay in the outpatient setting is an emerging safety priority that health information technology (HIT) should help address. However, diagnostic delays have persisted, and new safety concerns associated with the use of HIT have emerged. OBJECTIVE To analyze HIT-related outpatient diagnostic delays within a large, integrated health care system. DESIGN, SETTING, AND PARTICIPANTS This cohort study involved qualitative content analysis of safety concerns identified in aggregated root cause analysis (RCA) data related to HIT and outpatient diagnostic delays. The setting was the US Department of Veterans Affairs using all RCAs submitted to the Veterans Affairs (VA) National Center for Patient Safety from January 1, 2013, to July 31, 2018. MAIN OUTCOMES AND MEASURES Common themes associated with the role of HIT-related safety concerns were identified and categorized according to the Health IT Safety framework for measuring, monitoring, and improving HIT safety. This framework includes 3 related domains (ie, safe HIT, safe use of HIT, and using HIT to improve safety) situated within an 8-dimensional sociotechnical model accounting for interacting technical and nontechnical variables associated with safety. Hence, themes identified enhanced understanding of the sociotechnical context and domain of HIT safety involved. RESULTS Of 214 RCAs categorized by the terms delay and outpatient submitted during the study period, 88 were identified as involving diagnostic delays and HIT, from which 172 unique HIT-related safety concerns were extracted (mean [SD], 1.97 [1.53] per RCA). Most safety concerns (82.6% [142 of 172]) involved problems with safe use of HIT, predominantly sociotechnical factors associated with people, workflow and communication, and a poorly designed human-computer interface. Fewer safety concerns involved problems with safe HIT (14.5% [25 of 172]) or using HIT to improve safety (0.3% [5 of 172]). The following 5 key high-risk areas for diagnostic delays emerged: managing electronic health record inbox notifications and communication, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results. CONCLUSIONS AND RELEVANCE This qualitative study of a national RCA data set suggests that interventions to reduce outpatient diagnostic delays could aim to improve test result management, interoperability, data visualization, and order entry, as well as to decrease information overload.
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Affiliation(s)
- Lauren Powell
- Veterans Affairs (VA) National Center for Patient Safety, Ann Arbor, Michigan
| | - Dean F Sittig
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas
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Keizer RJ, Dvergsten E, Kolacevski A, Black A, Karovic S, Goswami S, Maitland ML. Get Real: Integration of Real‐World Data to Improve Patient Care. Clin Pharmacol Ther 2020; 107:722-725. [DOI: 10.1002/cpt.1784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/26/2019] [Indexed: 12/23/2022]
Affiliation(s)
| | | | | | - Aaron Black
- Inova Translational Medicine Institute Fairfax Virginia USA
| | | | | | - Michael L. Maitland
- Inova Schar Cancer Institute Fairfax Virginia USA
- University of Virginia Cancer Center Charlottesville Virginia USA
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18
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Majeed A, Morgan P. Authors’ reply to: Sepsis recognition algorithms add to the toxic NHS working environment. Assoc Med J 2020. [DOI: 10.1136/bmj.m263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Olson K, Marchalik D, Farley H, Dean SM, Lawrence EC, Hamidi MS, Rowe S, McCool JM, O'Donovan CA, Micek MA, Stewart MT. Organizational strategies to reduce physician burnout and improve professional fulfillment. Curr Probl Pediatr Adolesc Health Care 2019; 49:100664. [PMID: 31588019 DOI: 10.1016/j.cppeds.2019.100664] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Burnout is highly prevalent among physicians and has been associated with negative outcomes for physicians, patients, staff, and health-care organizations. Reducing physician burnout and increasing physician well-being is a priority. Systematic reviews suggest that organization-based interventions are more effective in reducing physician burnout than interventions targeted at individual physicians. This consensus review by leaders in the field across multiple institutions presents emerging trends and exemplary evidence-based strategies to improve professional fulfillment and reduce physician burnout using Stanford's tripartite model of physician professional fulfillment as an organizing framework: practice efficiency, culture, and personal resilience to support physician well-being. These strategies include leadership traits, latitude of control and autonomy, collegiality, diversity, teamwork, top-of-license workflows, electronic health record (EHR) usability, peer support, confidential mental health services, work-life integration and reducing barriers to practicing a healthy lifestyle. The review concludes with evidence-based recommendations on establishing an effective physician wellness program.
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Affiliation(s)
- Kristine Olson
- Yale School of Medicine, Yale New Haven Health, 20 York Street, New Haven, CT 06510, United States.
| | - Daniel Marchalik
- Medstar Health, Georgetown University School of Medicine, Washington, DC, United States
| | - Heather Farley
- Christiana Care Health System, Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, DE, United States
| | - Shannon M Dean
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | | | - Maryam S Hamidi
- Department of Psychiatry and Behavioral Sciences, Stanford Medicine WellMD Center, Stanford University, Stanford, CA, United States
| | - Susannah Rowe
- Boston Medical Center, Boston University School of Medicine, Boston, MA, United States
| | - Joanne M McCool
- The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | | | - Mark A Micek
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Miriam T Stewart
- The Children's Hospital of Philadelphia, Philadelphia, PA, United States
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20
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A Quality Initiative Reducing Adverse Outcomes in Pediatric Patients with DKA During Intrafacility Transit. Pediatr Qual Saf 2019; 4:e194. [PMID: 31572895 PMCID: PMC6708647 DOI: 10.1097/pq9.0000000000000194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 06/18/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction Treatment of diabetic ketoacidosis (DKA) requires close and timely monitoring to prevent serious adverse events. This quality improvement project details how our institution improved blood glucose monitoring around hospital admission. The project aimed to increase the blood glucose assessments for children with DKA receiving insulin in the emergency department (ED) within 30 minutes before transitioning to an inpatient unit. Methods We implemented a series of Plan-Do-Survey-Act (PDSA) cycles established by a multidisciplinary team for this project, with the primary outcome of obtaining the blood glucose level within 30 minutes before leaving the ED and secondarily preventing episodes of hypoglycemia. These PDSAs harnessed the electronic health record, to prompt and direct the medical staff, to improve blood glucose monitoring. Results From March 2015 to November 2017, we saw 640 patients in our ED for DKA. Of these, we admitted 629 to the inpatient unit with treatment that included continuous infusion of insulin. Over this period, we increased blood glucose monitoring for these patients within 30 minutes before the transition from 56% to >90%. Following the final PDSA cycle, we observed no reported episodes of hypoglycemia. Conclusion Using the functionality of the electronic health record, we showed significant, rapid, and sustained increases in compliance with the International Society for Pediatric and Adolescent Diabetes guideline by alerting ED staff caring for patients receiving continuous insulin around the time of care-team transitions. We believe that this program is easily replicable, cost-effective, and safety enhancing.
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21
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Shojania KG. Are increases in emergency use and hospitalisation always a bad thing? Reflections on unintended consequences and apparent backfires. BMJ Qual Saf 2019; 28:687-692. [DOI: 10.1136/bmjqs-2019-009406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2019] [Indexed: 11/04/2022]
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22
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Barnes EL, Ketwaroo GA, Shields HM. Scope of Burnout Among Young Gastroenterologists and Practical Solutions from Gastroenterology and Other Disciplines. Dig Dis Sci 2019; 64:302-306. [PMID: 30607687 DOI: 10.1007/s10620-018-5443-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Burnout is a critical issue among physicians, including gastroenterologists. Up to 50% of gastroenterologists have reported symptoms of burnout in national assessments, leading to increased recognition of the burden of burnout among subspecialty societies. Particularly alarming in these assessments of burnout is the suggestion of increased rates of burnout among trainees and early career gastroenterologists. In this article, we describe the scope of burnout among young gastroenterologists and the risk factors that contribute. In addition, we will offer practical solutions to reduce burnout based on insights developed from multidisciplinary approaches, including relevant burnout literature, organizational approaches within academic medical centers, and training programs, as well as interviews with successful private practice gastroenterologists, and leaders in the fields of business and education.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB #7080, Chapel Hill, NC, 27599-7080, USA. .,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Gyanprakash A Ketwaroo
- Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA.,Department of Medicine, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, Houston, TX, 77030, USA
| | - Helen M Shields
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA.,Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Whittington MD, Ho PM, Helfrich CD. Recommendations for the Use of Audit and Feedback to De-Implement Low-Value Care. Am J Med Qual 2019; 34:409-411. [PMID: 30654620 DOI: 10.1177/1062860618824153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Melanie D Whittington
- 1 VA Eastern Colorado Health Care System, Aurora, CO.,2 University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- 1 VA Eastern Colorado Health Care System, Aurora, CO.,2 University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Christian D Helfrich
- 3 VA Puget Sound Health Care System, Seattle, WA.,4 University of Washington, Seattle, WA
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Payne TH. EHR-related alert fatigue: minimal progress to date, but much more can be done. BMJ Qual Saf 2018; 28:1-2. [DOI: 10.1136/bmjqs-2017-007737] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2018] [Indexed: 11/04/2022]
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