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Campbell IM, Karavite DJ, Mcmanus ML, Cusick FC, Junod DC, Sheppard SE, Lourie EM, Shelov ED, Hakonarson H, Luberti AA, Muthu N, Grundmeier RW. Clinical decision support with a comprehensive in-EHR patient tracking system improves genetic testing follow up. J Am Med Inform Assoc 2023; 30:1274-1283. [PMID: 37080563 PMCID: PMC10280356 DOI: 10.1093/jamia/ocad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/10/2023] [Accepted: 04/11/2023] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVE We sought to develop and evaluate an electronic health record (EHR) genetic testing tracking system to address the barriers and limitations of existing spreadsheet-based workarounds. MATERIALS AND METHODS We evaluated the spreadsheet-based system using mixed effects logistic regression to identify factors associated with delayed follow up. These factors informed the design of an EHR-integrated genetic testing tracking system. After deployment, we assessed the system in 2 ways. We analyzed EHR access logs and note data to assess patient outcomes and performed semistructured interviews with users to identify impact of the system on work. RESULTS We found that patient-reported race was a significant predictor of documented genetic testing follow up, indicating a possible inequity in care. We implemented a CDS system including a patient data capture form and management dashboard to facilitate important care tasks. The system significantly sped review of results and significantly increased documentation of follow-up recommendations. Interviews with key system users identified a range of sociotechnical factors (ie, tools, tasks, collaboration) that contribute to safer and more efficient care. DISCUSSION Our new tracking system ended decades of workarounds for identifying and communicating test results and improved clinical workflows. Interview participants related that the system decreased cognitive and time burden which allowed them to focus on direct patient interaction. CONCLUSION By assembling a multidisciplinary team, we designed a novel patient tracking system that improves genetic testing follow up. Similar approaches may be effective in other clinical settings.
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Affiliation(s)
- Ian M Campbell
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Clinical Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of General Pediatrics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Applied Genomics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dean J Karavite
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Morgan L Mcmanus
- Division of Clinical Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Fred C Cusick
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David C Junod
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah E Sheppard
- Division of Clinical Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eli M Lourie
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of General Pediatrics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Eric D Shelov
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hakon Hakonarson
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Applied Genomics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anthony A Luberti
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Naveen Muthu
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of General Pediatrics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Mount-Campbell AF, Evans KD, Woods DD, Chipps E, Moffatt-Bruce SD, Patel K, Patterson ES. Uncovering the Value of a Historical Paper-Based Collaborative Artifact: The Nursing Unit's Kardex System. Front Digit Health 2020; 2:12. [PMID: 34713025 PMCID: PMC8521873 DOI: 10.3389/fdgth.2020.00012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/30/2020] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
| | - Kevin D Evans
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - David D Woods
- Department of Integrated Systems Engineering, The Ohio State University, Columbus, OH, United States
| | - Esther Chipps
- College of Nursing, The Ohio State University, Columbus, OH, United States.,Wexner Ohio State University Medical Center, Columbus, OH, United States
| | - Susan D Moffatt-Bruce
- Wexner Ohio State University Medical Center, Columbus, OH, United States.,Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Kashvi Patel
- Royal College of Physicians and Surgeons of Canada, Ottawa, ON, Canada.,College of Business, The Ohio State University, Columbus, OH, United States
| | - Emily S Patterson
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, United States
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Fraczkowski D, Matson J, Lopez KD. Nurse workarounds in the electronic health record: An integrative review. J Am Med Inform Assoc 2020; 27:1149-1165. [PMID: 32651588 PMCID: PMC7647365 DOI: 10.1093/jamia/ocaa050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 02/29/2020] [Accepted: 04/06/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The study sought to synthesize published literature on direct care nurses' use of workarounds related to the electronic health record. MATERIALS AND METHODS We conducted an integrative review of qualitative and quantitative peer-reviewed research through a structured search of Academic Search Complete, EBSCO Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Engineering Village, Ovid Medline, Scopus, and Web of Science. We systematically applied exclusion rules at the title, abstract, and full article stages and extracted and synthesized their research methods, workaround classifications, and probable causes from articles meeting inclusion criteria. RESULTS Our search yielded 5221 results. After removing duplicates and applying rules, 33 results met inclusion criteria. A total of 22 articles used qualitative approaches, 10 used mixed methods, and 1 used quantitative methods. While researchers may classify workarounds differently, they generally fit 1 of 3 broad categories: omission of process steps, steps performed out of sequence, and unauthorized process steps. Each study identified probable causes, which included technology, task, organizational, patient, environmental, and usability factors. CONCLUSIONS Extensive study of nurse workarounds in acute settings highlights the gap in ambulatory care research. Despite decades of electronic health record development, poor usability remains a key concern for nurses and other members of care team. The widespread use of workarounds by the largest group of healthcare providers subverts quality health care at every level of the healthcare system. Research is needed to explore the gaps in our understanding of and identify strategies to reduce workaround behaviors.
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Affiliation(s)
- Dan Fraczkowski
- Information Services, UI Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jeffrey Matson
- Department of Anesthesia, Northwestern Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Karen Dunn Lopez
- Center for Nursing Classification & Clinical Effectiveness, College of Nursing, The University of Iowa, Iowa City, Iowa, USA
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Carayon P, Hundt AS, Hoonakker P. Technology barriers and strategies in coordinating care for chronically ill patients. APPLIED ERGONOMICS 2019; 78:240-247. [PMID: 31046955 PMCID: PMC6529186 DOI: 10.1016/j.apergo.2019.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 03/18/2019] [Accepted: 03/22/2019] [Indexed: 05/18/2023]
Abstract
Care managers who coordinate care for chronically ill patients in hospitals and outpatient settings use multiple health information technologies for accessing, processing, documenting, and communicating patient-related information. Using a combination of 41 interviews and observations of 15 care managers, we identified a range of technology-related barriers experienced by care managers (total of 163 occurrences). The barriers are related to (lack of) access to information, inadequate information, limited usefulness and usability of the technologies, challenges associated with using multiple health IT, and technical problems. In 43% of the occurrences, care managers describe strategies to deal with the technology barriers; these fit in three categories: nothing/delay (9 occurrences), work-arounds (32 occurrences), and direct action at the individual, team, and organization levels (29 occurrences). Our data show the adaptive capacity of care managers who develop various strategies to deal with technology barriers and are, therefore, able to care for chronically ill patients. This information can be used as input to work system redesigns.
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Affiliation(s)
- Pascale Carayon
- Department of Industrial & Systems Engineering, University of Wisconsin-Madison, USA; Center for Quality and Productivity Improvement, University of Wisconsin-Madison, USA.
| | - Ann Schoofs Hundt
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, USA
| | - Peter Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, USA
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