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Sittig DF, Boxwala A, Wright A, Zott C, Gauthreaux NA, Swiger J, Lomotan EA, Dullabh P. Patient-centered clinical decision support challenges and opportunities identified from workflow execution models. J Am Med Inform Assoc 2024; 31:1682-1692. [PMID: 38907738 PMCID: PMC11258405 DOI: 10.1093/jamia/ocae138] [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: 03/07/2024] [Revised: 05/08/2024] [Accepted: 05/27/2024] [Indexed: 06/24/2024] Open
Abstract
OBJECTIVE To use workflow execution models to highlight new considerations for patient-centered clinical decision support policies (PC CDS), processes, procedures, technology, and expertise required to support new workflows. METHODS To generate and refine models, we used (1) targeted literature reviews; (2) key informant interviews with 6 external PC CDS experts; (3) model refinement based on authors' experience; and (4) validation of the models by a 26-member steering committee. RESULTS AND DISCUSSION We identified 7 major issues that provide significant challenges and opportunities for healthcare systems, researchers, administrators, and health IT and app developers. Overcoming these challenges presents opportunities for new or modified policies, processes, procedures, technology, and expertise to: (1) Ensure patient-generated health data (PGHD), including patient-reported outcomes (PROs), are documented, reviewed, and managed by appropriately trained clinicians, between visits and after regular working hours. (2) Educate patients to use connected medical devices and handle technical issues. (3) Facilitate collection and incorporation of PGHD, PROs, patient preferences, and social determinants of health into existing electronic health records. (4) Troubleshoot erroneous data received from devices. (5) Develop dashboards to display longitudinal patient-reported data. (6) Provide reimbursement to support new models of care. (7) Support patient engagement with remote devices. CONCLUSION Several new policies, processes, technologies, and expertise are required to ensure safe and effective implementation and use of PC CDS. As we gain more experience implementing and working with PC CDS, we should be able to begin realizing the long-term positive impact on patient health that the patient-centered movement in healthcare promises.
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Affiliation(s)
- Dean F Sittig
- Department of Clinical and Health Informatics, University of Texas Health Science Center, Houston, TX 77030, United States
| | - Aziz Boxwala
- Elimu Informatics, El Cerrito, CA 94530, United States
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Courtney Zott
- NORC at the University of Chicago, Bethesda, MD 20814, United States
| | | | - James Swiger
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD 20857, United States
| | - Edwin A Lomotan
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD 20857, United States
| | - Prashila Dullabh
- NORC at the University of Chicago, Bethesda, MD 20814, United States
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2
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Nuzzi A, Latorre V, Semisa D, Scozzi B. Improving the mental health care process in response to Covid-19 pandemic: The case of a penitentiary mental health division. PLoS One 2023; 18:e0293492. [PMID: 37903102 PMCID: PMC10615294 DOI: 10.1371/journal.pone.0293492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/29/2023] [Indexed: 11/01/2023] Open
Abstract
Covid-19 outbreak led all organizations to reorganize their processes to prevent infection and contagion risk. All healthcare facilities, included penitentiary mental health services, had to redesign their processes to safely deliver care services. In this paper, the case of a Penitentiary Mental Health Division located in southern Italy is presented. Soft System Methodology and Business process management principles and techniques are adopted to analyse and redesign the detainees' mental health care process. The process, characterized by direct, close and prolonged contact with patients, exposes detainees and healthcare staff to a high Covid-19 infection risk. Through document analysis, interviews with the actors involved in the process and direct observation, the process's inefficiencies and criticalities are identified. The process is redesigned to make it compliant with Covid-19 prevention provisions and national penitentiary regulations and address the other criticalities. The proposed methodological approach-which innovatively combines Soft System Methodology and Business Process Management-constitutes a human-centered process-based redesign approach that can be used both in healthcare and other organizational settings.
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Affiliation(s)
- Angela Nuzzi
- Department of Mechanics, Mathematics, and Management, Polytechnic University of Bari, Bari, Italy
| | - Valeria Latorre
- Complex Organization Unit Psychiatric Diagnosis and Care Service UO San Paolo, ASL Bari, Bari, Italy
- Penitentiary Mental Health Service, Department of Mental Health, ASL Bari, Bari, Italy
| | - Domenico Semisa
- Complex Organization Unit Psychiatric Diagnosis and Care Service UO San Paolo, ASL Bari, Bari, Italy
| | - Barbara Scozzi
- Department of Mechanics, Mathematics, and Management, Polytechnic University of Bari, Bari, Italy
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Thomas V, Kalidindi B, Waghmare A, Bhatia A, Raj T, Balsari S. The Vinyasa Tool for mHealth Solutions: Supporting Human-Centered Design in Nascent Digital Health Ecosystems. JMIR Form Res 2023; 7:e45250. [PMID: 37607881 PMCID: PMC10580130 DOI: 10.2196/45250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/18/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND mHealth (mobile health) systems have been deployed widely in low- and middle-income countries (LMICs) for health system strengthening, requiring considerable resource allocation. However, most solutions have not achieved scale or sustainability. Poor usability and failure to address perceived needs are among the principal reasons mHealth systems fail to achieve acceptance and adoption by health care workers. A human-centered design approach to improving mHealth system use requires an exploration of users' perceptions of mHealth systems, including the environmental, user-related, and technological aspects of a system. At present, there is a dearth of contextually intelligent tools available to mHealth developers that can guide such exploration before full-scale development and deployment. OBJECTIVE To develop a tool to aid optimization of mHealth solutions in LMICs to facilitate human-centered design and, consequently, successful adoption. METHODS We collated findings and themes from key qualitative studies on mHealth deployment in LMICs. We then used the Informatics Stack framework by Lehmann to label, sort, and collate findings and themes into a list of questions that explore the environment, users, artifacts, information governance, and interoperability of mHealth systems deployed in LMICs. RESULTS We developed the Vinyasa Tool to aid qualitative research about the need and usability of mHealth solutions in LMICs. The tool is a guide for focus group discussions and key informant interviews with community-based health care workers and primary care medical personnel who use or are expected to use proposed mHealth solutions. The tool consists of 71 questions organized in 11 sections that unpack and explore multiple aspects of mHealth systems from the perspectives of their users. These include the wider world and organization in which an mHealth solution is deployed; the roles, functions, workflow, and adoption behavior of a system's users; the security, privacy, and interoperability afforded by a system; and the artifacts of an information system-the data, information, knowledge, algorithms, and technology that constitute the system. The tool can be deployed in whole or in part, depending on the context of the study. CONCLUSIONS The Vinyasa Tool is the first such comprehensive qualitative research instrument incorporating questions contextualized to the LMIC setting. We expect it to find wide application among mHealth developers, health system administrators, and researchers developing and deploying mHealth tools for use by patients, providers, and administrators. The tool is expected to guide users toward human-centered design with the goal of improving relevance, usability, and, therefore, adoption.
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Affiliation(s)
- Verghese Thomas
- Division of Medical Informatics, St John's Research Institute, Bangalore, India
| | - Bharat Kalidindi
- Division of Medical Informatics, St John's Research Institute, Bangalore, India
| | - Abijeet Waghmare
- Division of Medical Informatics, St John's Research Institute, Bangalore, India
| | - Abhishek Bhatia
- Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Tony Raj
- Division of Medical Informatics, St John's Research Institute, Bangalore, India
- Department of Physiology, St John's Medical College, Bangalore, India
| | - Satchit Balsari
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
- François-Xavier Bagnoud Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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4
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Legenza L, Morris AO, Safdar N, Chui MA. "What brought you in today?": Modeling patient-provider clinic visits to characterize rural providers' antibiotic treatment decisions. Res Social Adm Pharm 2023; 19:896-905. [PMID: 36870816 PMCID: PMC10206756 DOI: 10.1016/j.sapharm.2023.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 12/05/2022] [Accepted: 02/16/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Designing clinical decision support (CDS) tools is challenging because clinical decision-making must account for an invisible task load: incorporating non-linear objective and subjective factors to make an assessment and treatment plan. This calls for a cognitive task analysis approach. OBJECTIVES The objectives of this study were to 1.) understand healthcare providers' decision making during a typical clinic visit, and 2.) explore how antibiotic treatment decisions are made when they arise. METHODS Two cognitive task analysis methods were applied - Hierarchical Task Analysis (HTA) and Operations Sequence Diagramming (OSD) - to 39 h of observational data collected at family medicine, urgent care, and emergency medicine clinical sites. RESULTS The resulting HTA models included a coding taxonomy detailing ten cognitive goals and associated sub-goals and demonstrated how the goals occur as interactions between the provider and electronic health record, the patient, and the physical clinic environment. Although the HTA detailed resources for antibiotic treatment decisions, antibiotics were a minority of drug classes ordered. The OSD shows the sequence of events and when decisions are made solely at the provider level and when shared decision making occurs with the patient. Qualitative data from the observations informed a constructed vignette case example portraying select tasks from the HTA. CONCLUSIONS These findings emphasize that the scope of disease states presenting to a generalist clinical setting is broad and could include acute exacerbations of rare diseases within a time-pressured environment. CDS must be accessible, time efficient, and fit within the resource gathering task before treatment decisions are made.
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Affiliation(s)
- Laurel Legenza
- Sonderegger Research Center for Improved Medication Outcomes, University of Wisconsin-Madison School of Pharmacy, 777 Highland Ave., Madison, WI, 53705, United States.
| | - Ashley O Morris
- University of Wisconsin-Madison School of Pharmacy, Social and Administrative Sciences Division, 777 Highland Ave., Madison, WI, 53705, United States
| | - Nasia Safdar
- University of Wisconsin School of Medicine and Public Health, 750 Highland Ave., Madison, WI, 53705, United States
| | - Michelle A Chui
- Sonderegger Research Center for Improved Medication Outcomes, University of Wisconsin-Madison School of Pharmacy, 777 Highland Ave., Madison, WI, 53705, United States; University of Wisconsin-Madison School of Pharmacy, Social and Administrative Sciences Division, 777 Highland Ave., Madison, WI, 53705, United States
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5
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Wu DTY, Murdock P, Vennemeyer S, Mynatt JM, Chih MY. Challenges in inpatient care coordinators’ clinical workflow and opportunities in designing a health IT solution: A mixed methods study. INTERNATIONAL JOURNAL OF CARE COORDINATION 2022. [DOI: 10.1177/20534345221111004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Inpatient care coordinators (ICCs) in the United States play a critical role in case management and care transition. ICCs spend a large amount of time in chart review and documentation through electronic health record (EHR) systems. However, significant knowledge gaps exist regarding their workflow barriers and their use of health information technology (Health IT). Using only quantitative or quantitative methods does not provide a comprehensive picture about ICC’s workflow due to its complex and dynamic nature. This work aimed to address this gap by conducting a mixed-methods study to understand the workflow of ICCs and identifying challenges in care deliver and documentation activities. Methods The study adopted a concurrent triangulation design including qualitative interviews with 12 ICC staff members in the United States followed by extraction of their EHR event logs for one month. The qualitative interview data were analyzed thematically, and the log data were analyzed statistically. The results were triangulated and interpreted. Results Three major workflow barriers faced by ICCs were identified: long travel time, heavy documentation load, and suboptimal communication. The event logs provided empirical evidence to support the workflow barriers identified in the interviews, especially in travel time and documentation load. Discussion ICC workflow has several inefficiencies. The study generated four design considerations to develop a Health IT solution: Mobility, EHR integration, Team-based Communication, and User Adoption to improve workflow efficiency and care coordination. Using a mixed-methods approach is effective and efficient in collecting and analyzing clinical workflow.
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Affiliation(s)
- Danny TY Wu
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Medical Sciences Baccalaureate Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Paul Murdock
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Medical Sciences Baccalaureate Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott Vennemeyer
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Medical Sciences Baccalaureate Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Janie M Mynatt
- Department of Social Work, Care Management and Spiritual Care, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Ming-Yuan Chih
- Department of Clinical Leadership and Management, University of Kentucky College of Health Sciences, Lexington, KY, USA
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6
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Miller SD, Huang JS, Gurses AP. Telemedicine Workflow Modeling in Pediatric Gastroenterology. J Pediatr Gastroenterol Nutr 2022; 74:433-434. [PMID: 35129157 DOI: 10.1097/mpg.0000000000003393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Steven D Miller
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeannie S Huang
- Division of Pediatric Gastroenterology, Rady Children's Hospital and University of California San Diego, San Diego, CA
| | - Ayse P Gurses
- Anesthesiology and Critical Care, Emergency Medicine, and Health Sciences Informatics, School of Medicine, Armstrong Institute Center for Health Care Human Factors, Johns Hopkins University, Baltimore, MD
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7
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Davis S, Antonio M, Smith M, Burgener P, Lavallee DC, Price M, Fletcher SC, Lau F. Paving the Way for Electronic Patient-Centered Measurement in Team-Based Primary Care: Integrated Knowledge Translation Approach. JMIR Form Res 2022; 6:e33584. [PMID: 35302508 PMCID: PMC8976252 DOI: 10.2196/33584] [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: 09/24/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 11/23/2022] Open
Abstract
Background Patient-centered measurement (PCM) aims to improve the overall quality of care through the collection and sharing of patient values, outcomes, and perspectives. However, the use of PCM in care team decisions remains limited. Integrated knowledge translation (IKT) offers a collaborative, adaptive approach to explore best practices for incorporating PCM into primary care practices by involving knowledge users, including patients and providers, in the exploratory process. Objective This study aims to test the feasibility of using patient-generated data in team-based care; describe the use of these data for team-based mental health care; and summarize patient and provider care experiences with PCM. Methods We conducted a multi-method exploratory study in a rural team-based primary care clinic using IKT to co-design, implement, and evaluate the use of PCM in team-based mental health care. Care pathways, workflows, and quality improvement activities were adjusted iteratively to improve integration efforts. Patient and provider experiences were evaluated using individual interviews relating to the use of PCM and patient portals in practice. All meeting notes, interview summaries, and emails were analyzed to create a narrative evaluation. Results During co-design, a care workflow was developed to incorporate electronically collected patient-generated data from the patient portal into the electronic medical record, and customized educational tools and resources were added. During implementation, care pathways and patient workflows for PCM were developed. Patients found portal use easy, educational, and validating, but data entries were not used during care visits. Providers saw the portal as extra work, and the lack of portal and electronic medical record integration was a major barrier. The IKT approach was invaluable for addressing workflow changes and understanding the ongoing barriers to PCM use and quality improvement. Conclusions Although the culture toward using PCM is changing, the use of PCM during care has not been successful. Patients felt validated and supported through portal use and could be empowered to bring these data to their visits. Training, modeling, and adaptable PCM methods are required before PCM can be integrated into routine care.
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Affiliation(s)
- Selena Davis
- School of Health Information Science, University of Victoria, Victoria, BC, Canada
| | - Marcy Antonio
- School of Information, University of Michigan, Ann Arbor, MI, United States
| | - Mindy Smith
- College of Human Medicine, Michigan State University, Grand Rapids, MI, United States.,Patient Advisory Committee, Kootenay Boundary Collaborative Services Committee, Castlegar, BC, Canada
| | - Paul Burgener
- Patient Voices Network, BC Patient Safety & Quality Council, Vancouver, BC, Canada
| | | | - Morgan Price
- Innovation and Support Unit, Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sarah C Fletcher
- Innovation and Support Unit, Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Francis Lau
- School of Health Information Science, University of Victoria, Victoria, BC, Canada
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8
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Mishra AN, Tao Y, Keil M, Oh JH(C. Functional IT Complementarity and Hospital Performance in the United States: A Longitudinal Investigation. INFORMATION SYSTEMS RESEARCH 2022. [DOI: 10.1287/isre.2021.1064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
For healthcare practitioners and policymakers, one of the most challenging problems is understanding how to implement health information technology (HIT) applications in a way that yields the most positive impacts on quality and cost of care. We identify four clinical HIT functions which we label as order entry and management (OEM), decision support (DS), electronic clinical documentation (ECD), and results viewing (RV). We view OEM and DS as primary clinical functions and ECD and RV as support clinical functions. Our results show that no single combination of applications uniformly improves clinical and experiential quality and reduces cost for all hospitals. Thus, managers must assess which HIT interactions improve which performance metric under which conditions. Our results suggest that synergies can be realized when these systems are implemented simultaneously. Additionally, synergies can occur when support HIT is implemented before primary HIT and irrespective of the order in which primary HITs are implemented. Practitioners should also be aware that the synergistic effects of HITs and their impact on cost and quality are different for chronic and acute diseases. Our key message to top managers is to prioritize different combinations of HIT contingent on the performance variables they are targeting for their hospitals but also to realize that technology may not impact all outcomes.
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Affiliation(s)
- Abhay Nath Mishra
- Debbie and Jerry Ivy College of Business, Information Systems & Business Analytics, Iowa State University, Ames, Iowa 50011
| | - Youyou Tao
- College of Business Administration, Information Systems & Business Analytics, Loyola Marymount University, Los Angeles, California 90045
| | - Mark Keil
- J. Mack Robinson College of Business, Department of Computer Information Systems, Georgia State University, Atlanta, Georgia 30303
| | - Jeong-ha (Cath) Oh
- Department of Computer Information Systems, Georgia State University, Atlanta, Georgia 30302
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9
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Derrick T, Harrington KRV, Alohan DI, Sullivan PS, Holland DP, Klepser DG, Quamina A, Siegler AJ, Young HN. Integrating and Disseminating Pre-Exposure Prophylaxis (PrEP) Screening and Dispensing for Black Men Who Have Sex With Men in Atlanta, Georgia: Protocol for Community Pharmacies. JMIR Res Protoc 2022; 11:e35590. [PMID: 35138252 PMCID: PMC8867290 DOI: 10.2196/35590] [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: 12/17/2021] [Accepted: 12/24/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Black men who have sex with men (BMSM) suffer from alarmingly high rates of HIV in the United States. Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV infection by 99% among men who have sex with men, yet profound racial disparities in the uptake of PrEP persist. Low PrEP uptake in BMSM is driven by poor access to PrEP, including inconvenient locations of PrEP-prescribing physicians, distrust of physicians, and stigma, which limit communication about PrEP and its side effects. Previous work indicates that offering HIV prevention services in pharmacies located in low-income, underserved neighborhoods is feasible and can reduce stigma because pharmacies offer a host of less stigmatized health services (eg, vaccinations). We present a protocol for a pharmacy PrEP model that seeks to address challenges and barriers to pharmacy-based PrEP specifically for BMSM. OBJECTIVE We aim to develop a sustainable pharmacy PrEP delivery model for BMSM that can be implemented to increase PrEP access in low-income, underserved neighborhoods. METHODS This study design is a pilot intervention to test a pharmacy PrEP delivery model among pharmacy staff and BMSM. We will examine the PrEP delivery model's feasibility, acceptability, and safety and gather early evidence of its impact and cost with respect to PrEP uptake. A mixed-methods approach will be performed, including three study phases: (1) a completed formative phase with qualitative interviews from key stakeholders; (2) a completed transitional pilot phase to assess customer eligibility and willingness to receive PrEP in pharmacies during COVID-19; and (3) a planned pilot intervention phase which will test the delivery model in 2 Atlanta pharmacies in low-income, underserved neighborhoods. RESULTS Data from the formative phase showed strong support of pharmacy-based PrEP delivery among BMSM, pharmacists, and pharmacy staff. Important factors were identified to facilitate the implementation of PrEP screening and dissemination in pharmacies. During the transitional pilot phase, we identified 81 individuals who would have been eligible for the pilot phase. CONCLUSIONS Pharmacies have proven to be a feasible source for offering PrEP for White men who have sex with men but have failed to reach the most at-risk, vulnerable population (ie, BMSM). Increasing PrEP access and uptake will reduce HIV incidence and racial inequities in HIV. Translational studies are required to build further evidence and scale pharmacy-based PrEP services specifically for populations that are disconnected from HIV prevention resources. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/35590.
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Affiliation(s)
| | - Kristin R V Harrington
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Daniel I Alohan
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Patrick S Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - David P Holland
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States.,Division of Medical and Preventative Services, Fulton County Board of Health, Atlanta, GA, United States
| | - Donald G Klepser
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, United States
| | - Alvan Quamina
- National AIDS Education and Services for Minorities Inc, Atlanta, GA, United States
| | - Aaron J Siegler
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Henry N Young
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, United States
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10
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Physical and information workflow mapping of vancomycin therapeutic drug management: A single site case study revealing potential gaps in the process. J Med Syst 2021; 45:104. [PMID: 34705113 DOI: 10.1007/s10916-021-01784-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022]
Abstract
Vancomycin is one of the most prescribed antibiotics in pediatric intensive care units (PICU) in US hospitals. However, a detailed understanding of workflow and information flow among various stakeholders regarding vancomycin treatment processes in clinical settings is lacking. We conducted direct observations and informant interviews to develop the mapping of key processes and information flow for vancomycin treatment, with an emphasis on therapeutic drug monitoring (TDM) dose adjustment decision-making. A health information technology (HIT) sociotechnical framework was used to identify EHR related safety concerns. A total of 27 vancomycin treatment activities were observed over a 60-h duration including infusion administration, infusion completion, trough concentration blood draw and therapeutic decision making processes. Workflow and information flow mappings revealed (1) deviations between the documented timestamp used for TDM decision making and the actual time the tasks executed and (2) the lack of information flow regarding infusion completion and interruption. Missing features, insufficient usability and lack of integration with workflow and communication in the EHR were deemed safety gaps that may affect the accuracy of therapeutic decisions. Our case study identified gaps in information flow among clinical team members via EHR in TDM processes to provide insights for the improvement of the EHR system for antibiotic treatment purposes. In particular, the potential harm of the missing, uncertain, and inaccurate documented TDM task times warrant further investigations.
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11
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Savoy A, Saleem JJ, Barker BC, Patel H, Kara A. Mobile technology for hospitalists: Clinician perspectives and unmet needs from a workflow analysis. JMIR Hum Factors 2021; 9:e28783. [PMID: 34643530 PMCID: PMC8767475 DOI: 10.2196/28783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/01/2021] [Accepted: 10/10/2021] [Indexed: 11/15/2022] Open
Abstract
Background The hospitalist workday is cognitively demanding and dominated by activities away from patients’ bedsides. Although mobile technologies are offered as solutions, clinicians report lower expectations of mobile technology after actual use. Objective The purpose of this study is to better understand opportunities for integrating mobile technology and apps into hospitalists’ workflows. We aim to identify difficult tasks and contextual factors that introduce inefficiencies and characterize hospitalists’ perspectives on mobile technology and apps. Methods We conducted a workflow analysis based on semistructured interviews. At a Midwestern US medical center, we recruited physicians and nurse practitioners from hospitalist and inpatient teaching teams and internal medicine residents. Interviews focused on tasks perceived as frequent, redundant, and difficult. Additionally, participants were asked to describe opportunities for mobile technology interventions. We analyzed contributing factors, impacted workflows, and mobile app ideas. Results Over 3 months, we interviewed 12 hospitalists. Participants collectively identified chart reviews, orders, and documentation as the most frequent, redundant, and difficult tasks. Based on those tasks, the intake, discharge, and rounding workflows were characterized as difficult and inefficient. The difficulty was associated with a lack of access to electronic health records at the bedside. Contributing factors for inefficiencies were poor usability and inconsistent availability of health information technology combined with organizational policies. Participants thought mobile apps designed to improve team communications would be most beneficial. Based on our analysis, mobile apps focused on data entry and presentation supporting specific tasks should also be prioritized. Conclusions Based on our results, there are prioritized opportunities for mobile technology to decrease difficulty and increase the efficiency of hospitalists’ workflows. Mobile technology and task-specific mobile apps with enhanced usability could decrease overreliance on hospitalists’ memory and fragmentation of clinical tasks across locations. This study informs the design and implementation processes of future health information technologies to improve continuity in hospital-based medicine.
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Affiliation(s)
- April Savoy
- Center for Health Information and Communication, Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Indianapolis, US.,Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indianapolis, Indianapolis, US.,Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, US
| | - Jason J Saleem
- Department of Industrial Engineering, J.B. Speed School of Engineering, University of Louisville, Louisville, US
| | - Barry C Barker
- Center for Health Information and Communication, Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Indianapolis, US
| | - Himalaya Patel
- Center for Health Information and Communication, Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Indianapolis, US
| | - Areeba Kara
- Indiana University Health Physicians, Indianapolis, US.,Indiana University School of Medicine, Indianapolis, US
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12
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Lin TC, Hwang LL, Dai HD, Sang YC. Daily Care Information System Requirements: Professional Service-Driven Service Blueprint Approach. Appl Clin Inform 2021; 12:960-968. [PMID: 34644806 PMCID: PMC8514269 DOI: 10.1055/s-0041-1736222] [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: 04/19/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Long-term care (LTC) services are a professional service-driven (PSD) system; to deliver appropriate care services to residents, health care providers first need to collect appropriate patient data and make a professional assessment. A well-designed LTC information system should therefore consider the information requirements of multidisciplinary health care providers to adequately support their care services. OBJECTIVES This study proposed a modified service blueprint-the PSD service blueprint-for visualizing interdisciplinary service providers' input and output information requirements, which correspond to their service activities. METHODS The PSD service blueprint comprises five layers and seven elements. We also present a case study to illustrate the blueprint's application to daily LTC services. RESULTS Our proposed approach could clearly illustrate the daily care activities, service providers (main actors), actors' input and output information, and suggestions for LTC information system-related applications. CONCLUSION The proposed PSD service blueprint can not only gather interdisciplinary LTC service providers' information system requirements but also act as a mapping tool for visualizing the care service process.
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Affiliation(s)
- Tung-Cheng Lin
- Department of Information Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Lih-Lian Hwang
- Department of Healthcare Information and Management, School of Health Technology, Ming Chuan University, Taoyuan, Taiwan
| | - Hung-da Dai
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Chun Sang
- General Affairs Department, Noble Healthcare & Rehabilitation, Taipei, Taiwan
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13
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Lall D, Engel N, Devadasan N, Horstman K, Criel B. Team-based primary health care for non-communicable diseases: complexities in South India. Health Policy Plan 2021; 35:ii22-ii34. [PMID: 33156934 PMCID: PMC7646724 DOI: 10.1093/heapol/czaa121] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 12/26/2022] Open
Abstract
Chronic non-communicable diseases (NCDs), such as diabetes and cardiovascular diseases, have reached epidemic proportions worldwide. Health systems, especially those in low- and middle-income countries, such as India, struggle to deliver quality chronic care. A reorganization of healthcare service delivery is needed to strengthen care for chronic conditions. In this study, we evaluated the implementation of a package of tailored interventions to reorganize care, which were identified following a detailed analysis of gaps in delivering quality NCD care at the primary care level in India. Interventions included a redesign of the workflow at primary care clinics, a redistribution of tasks, the introduction of patient information records and the involvement of community health workers in the follow-up of patients with NCDs. An experimental case study design was chosen to study the implementation of the quality improvement measures. Three public primary care facilities in rural South India were selected. Qualitative methods were used to gain an in-depth understanding of the implementation process and outcomes of implementation. Observations, field notes and semi-structured interviews with staff at these facilities (n = 15) were thematically analysed to identify contextual factors that influenced implementation. Only one of the primary health centres implemented all components of the intervention by the end of 9 months. The main barriers to implementation were hierarchical arrangements that inhibited team-based care, the amount of time required for counselling and staff transfers. Team cohesion, additional staff and staff motivation seem to have facilitated implementation. This quality improvement research highlights the importance of building relational leadership to enable team-based care at primary care clinics in India. Redesigned organization of care and task redistribution is important solutions to deliver quality chronic care. However, implementing these will require capacity building of local primary care teams.
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Affiliation(s)
- Dorothy Lall
- Institute of Public Health, 3009, II-A Main, 17th Cross, KR Rd, Siddanna Layout, Banashankari Stage II, Banashankari, Bengaluru, Karnataka, 560070 India
| | - Nora Engel
- Department of Health, Ethics & Society, CAPHRI Care and Public Health Research Institute, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Narayanan Devadasan
- Institute of Public Health, 3009, II-A Main, 17th Cross, KR Rd, Siddanna Layout, Banashankari Stage II, Banashankari, Bengaluru, Karnataka, 560070 India
| | - Klasien Horstman
- Department of Health, Ethics & Society, CAPHRI Care and Public Health Research Institute, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Bart Criel
- Institute of Tropical Medicine, Nationalestraat 155, Antwerpen 2000, Belgium
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14
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Hussain MI, Figueiredo MC, Tran BD, Su Z, Molldrem S, Eikey EV, Chen Y. A scoping review of qualitative research in JAMIA: past contributions and opportunities for future work. J Am Med Inform Assoc 2021; 28:402-413. [PMID: 33225361 DOI: 10.1093/jamia/ocaa179] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 08/07/2020] [Accepted: 07/17/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Qualitative methods are particularly well-suited to studying the complexities and contingencies that emerge in the development, preparation, and implementation of technological interventions in real-world clinical practice, and much remains to be done to use these methods to their full advantage. We aimed to analyze how qualitative methods have been used in health informatics research, focusing on objectives, populations studied, data collection, analysis methods, and fields of analytical origin. METHODS We conducted a scoping review of original, qualitative empirical research in JAMIA from its inception in 1994 to 2019. We queried PubMed to identify relevant articles, ultimately including and extracting data from 158 articles. RESULTS The proportion of qualitative studies increased over time, constituting 4.2% of articles published in JAMIA overall. Studies overwhelmingly used interviews, observations, grounded theory, and thematic analysis. These articles used qualitative methods to analyze health informatics systems before, after, and separate from deployment. Providers have typically been the main focus of studies, but there has been an upward trend of articles focusing on healthcare consumers. DISCUSSION While there has been a rich tradition of qualitative inquiry in JAMIA, its scope has been limited when compared with the range of qualitative methods used in other technology-oriented fields, such as human-computer interaction, computer-supported cooperative work, and science and technology studies. CONCLUSION We recommend increased public funding for and adoption of a broader variety of qualitative methods by scholars, practitioners, and policy makers and an expansion of the variety of participants studied. This should lead to systems that are more responsive to practical needs, improving usability, safety, and outcomes.
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Affiliation(s)
- Mustafa I Hussain
- Department of Informatics, Donald Bren School of Informatics and Computer Science, University of California Irvine, Irvine, California, USA
| | - Mayara Costa Figueiredo
- Department of Informatics, Donald Bren School of Informatics and Computer Science, University of California Irvine, Irvine, California, USA
| | - Brian D Tran
- Department of Informatics, Donald Bren School of Informatics and Computer Science, University of California Irvine, Irvine, California, USA.,Medical Scientist Training Program, School of Medicine, University of California Irvine, Irvine, California, USA
| | - Zhaoyuan Su
- Department of Informatics, Donald Bren School of Informatics and Computer Science, University of California Irvine, Irvine, California, USA
| | - Stephen Molldrem
- Department of Anthropology, University of California Irvine, Irvine, California, USA
| | - Elizabeth V Eikey
- Department of Family Medicine and Public Health & Design Lab, University of California San Diego, San Diego, California, USA
| | - Yunan Chen
- Department of Informatics, Donald Bren School of Informatics and Computer Science, University of California Irvine, Irvine, California, USA
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15
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Steitz BD, Sulieman L, Warner JL, Fabbri D, Brown JT, Davis AL, Unertl KM. Classification and analysis of asynchronous communication content between care team members involved in breast cancer treatment. JAMIA Open 2021; 4:ooab049. [PMID: 34396056 PMCID: PMC8358477 DOI: 10.1093/jamiaopen/ooab049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/06/2021] [Accepted: 06/16/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE A growing research literature has highlighted the work of managing and triaging clinical messages as a major contributor to professional exhaustion and burnout. The goal of this study was to discover and quantify the distribution of message content sent among care team members treating patients with breast cancer. MATERIALS AND METHODS We analyzed nearly two years of communication data from the electronic health record (EHR) between care team members at Vanderbilt University Medical Center. We applied natural language processing to perform sentence-level annotation into one of five information types: clinical, medical logistics, nonmedical logistics, social, and other. We combined sentence-level annotations for each respective message. We evaluated message content by team member role and clinic activity. RESULTS Our dataset included 81 857 messages containing 613 877 sentences. Across all roles, 63.4% and 21.8% of messages contained logistical information and clinical information, respectively. Individuals in administrative or clinical staff roles sent 81% of all messages containing logistical information. There were 33.2% of messages sent by physicians containing clinical information-the most of any role. DISCUSSION AND CONCLUSION Our results demonstrate that EHR-based asynchronous communication is integral to coordinate care for patients with breast cancer. By understanding the content of messages sent by care team members, we can devise informatics initiatives to improve physicians' clerical burden and reduce unnecessary interruptions.
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Affiliation(s)
- Bryan D Steitz
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lina Sulieman
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeremy L Warner
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel Fabbri
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J Thomas Brown
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alyssa L Davis
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kim M Unertl
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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16
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Staras S, Tauscher JS, Rich N, Samarah E, Thompson LA, Vinson MM, Muszynski MJ, Shenkman EA. Using a Clinical Workflow Analysis to Enhance eHealth Implementation Planning: Tutorial and Case Study. JMIR Mhealth Uhealth 2021; 9:e18534. [PMID: 33626016 PMCID: PMC8047797 DOI: 10.2196/18534] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/16/2020] [Accepted: 02/22/2021] [Indexed: 11/13/2022] Open
Abstract
eHealth apps often fail to improve clinical outcomes due to poor integration with clinical workflow-the sequence and personnel needed to undertake a series of tasks for clinical care. Our central thesis is that eHealth interventions will be more effective if the clinical workflow is studied and taken into consideration for intervention implementation. This paper aims to provide an introductory tutorial on when and how to use a clinical workflow analysis to guide the implementation of eHealth interventions. The tutorial includes a step-by-step guide to conducting a clinical workflow analysis in planning for eHealth implementation. We began with a description of why a clinical workflow analysis is best completed before the implementation of eHealth interventions. Next, we described 4 steps needed to perform the clinical workflow analysis: the identification of discrete workflow components, workflow assessment, triangulation, and the stakeholder proposal of intervention implementation. Finally, we presented a case study of a clinical workflow analysis, which was conducted during patient visits of patients aged 11 or 12 years from 4 diverse pediatric or family medicine clinics to plan the implementation of a tablet-based app for adolescent vaccination. Investigators planning the implementation of new eHealth interventions in health care settings can use the presented steps to assess clinical workflow, thereby maximizing the match of their intervention with the clinical workflow. Conducting a prospective workflow study allows for evidence-based planning, identifying potential pitfalls, and increasing stakeholder buy-in and engagement. This tutorial should aid investigators in increasing the successful implementation of eHealth interventions.
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Affiliation(s)
- Stephanie Staras
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
- Institute for Child Health Policy, University of Florida, Gainesville, FL, United States
| | - Justin S Tauscher
- Behavioral Research in Technology and Engineering Center, Department of Psychiatry, University of Washington, Seattle, WA, United States
| | - Natalie Rich
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
- Department of Radiology, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Esaa Samarah
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
- Institute for Child Health Policy, University of Florida, Gainesville, FL, United States
- College of Social Work, Florida State University, Tallahassee, FL, United States
| | - Lindsay A Thompson
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
- Institute for Child Health Policy, University of Florida, Gainesville, FL, United States
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Michelle M Vinson
- Department of Clinical Sciences, Florida State University College of Medicine Orlando Regional Campus, Orlando, FL, United States
| | - Michael J Muszynski
- Department of Clinical Sciences, Florida State University College of Medicine Orlando Regional Campus, Orlando, FL, United States
| | - Elizabeth A Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
- Institute for Child Health Policy, University of Florida, Gainesville, FL, United States
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17
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Zheng L, Duncan BJ, Kaufman DR, Furniss SK, Grando A, Poterack KA, Helmers RA, Miksch TA, Doebbeling BN. EHR Conversion on the PreOp Care: A Pre-Post Workflow Comparison. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2021; 2020:1402-1411. [PMID: 33936516 PMCID: PMC8075530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The impact of EHRs conversion on clinicians' daily work is crucial to evaluate the success of the intervention for Hospitals and to yield valuable insights into quality improvement. To assess the impact of different EHR systems on the preoperative nursing workflow, we used a structured framework combining quantitative time and motion study and qualitative cognitive analysis to characterize, visualize and explain the differences before and after an EHR conversion. The results showed that the EHR conversion brought a significant decrease in the patient case time and a reduced percentage of time using EHR. PreOp nurses spent a higher proportion of time caring for the patient, while the important tasks were completed in a more continuous pattern after the EHR conversion. The workflow variance was due to different nurse's cognitive process and the task time change was reduced because of some new interface features in the new EHR systems.
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Affiliation(s)
- Lu Zheng
- College of Health Solutions, Arizona State University, AZ, US
| | | | | | - Stephanie K Furniss
- College of Health Solutions, Arizona State University, AZ, US
- Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Adela Grando
- College of Health Solutions, Arizona State University, AZ, US
- Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Karl A Poterack
- Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
- Department of Anesthesiology, Mayo Clinic, AZ, US
| | - Richard A Helmers
- Department of Pulmonary Medicine, Mayo Clinic Health System, Northwest, Wisconsin, Eau Claire, WI, US
| | - Timothy A Miksch
- Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Brad N Doebbeling
- College of Health Solutions, Arizona State University, AZ, US
- Informatics and Knowledge Management, Mayo Clinic, Rochester, MN, US
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18
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Senathirajah Y, Kaufman DR, Cato KD, Borycki EM, Fawcett JA, Kushniruk AW. Characterizing and Visualizing Display and Task Fragmentation in the Electronic Health Record: Mixed Methods Design. JMIR Hum Factors 2020; 7:e18484. [PMID: 33084580 PMCID: PMC7641790 DOI: 10.2196/18484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/10/2020] [Accepted: 08/21/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The complexity of health care data and workflow presents challenges to the study of usability in electronic health records (EHRs). Display fragmentation refers to the distribution of relevant data across different screens or otherwise far apart, requiring complex navigation for the user's workflow. Task and information fragmentation also contribute to cognitive burden. OBJECTIVE This study aims to define and analyze some of the main sources of fragmentation in EHR user interfaces (UIs); discuss relevant theoretical, historical, and practical considerations; and use granular microanalytic methods and visualization techniques to help us understand the nature of fragmentation and opportunities for EHR optimization or redesign. METHODS Sunburst visualizations capture the EHR navigation structure, showing levels and sublevels of the navigation tree, allowing calculation of a new measure, the Display Fragmentation Index. Time belt visualizations present the sequences of subtasks and allow calculation of proportion per instance, a measure that quantifies task fragmentation. These measures can be used separately or in conjunction to compare EHRs as well as tasks and subtasks in workflows and identify opportunities for reductions in steps and fragmentation. We present an example use of the methods for comparison of 2 different EHR interfaces (commercial and composable) in which subjects apprehend the same patient case. RESULTS Screen transitions were substantially reduced for the composable interface (from 43 to 14), whereas clicks (including scrolling) remained similar. CONCLUSIONS These methods can aid in our understanding of UI needs under complex conditions and tasks to optimize EHR workflows and redesign.
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Affiliation(s)
- Yalini Senathirajah
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - David R Kaufman
- Medical Informatics Program, School of Health Professions, State University of New York - Downstate Health Sciences University, Brooklyn, NY, United States
| | - Kenrick D Cato
- School of Nursing, Columbia University, New York, NY, United States
| | - Elizabeth M Borycki
- School of Health Information Science, University of Victoria, Victoria, BC, Canada
| | - Jaime Allen Fawcett
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Andre W Kushniruk
- School of Health Information Science, University of Victoria, Victoria, BC, Canada
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19
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Roosan D, Law AV, Karim M, Roosan M. Improving Team-Based Decision Making Using Data Analytics and Informatics: Protocol for a Collaborative Decision Support Design. JMIR Res Protoc 2019; 8:e16047. [PMID: 31774412 PMCID: PMC6906625 DOI: 10.2196/16047] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/22/2019] [Accepted: 09/23/2019] [Indexed: 01/25/2023] Open
Abstract
Background According to the September 2015 Institute of Medicine report, Improving Diagnosis in Health Care, each of us is likely to experience one diagnostic error in our lifetime, often with devastating consequences. Traditionally, diagnostic decision making has been the sole responsibility of an individual clinician. However, diagnosis involves an interaction among interprofessional team members with different training, skills, cultures, knowledge, and backgrounds. Moreover, diagnostic error is prevalent in the interruption-prone environment, such as the emergency department, where the loss of information may hinder a correct diagnosis. Objective The overall purpose of this protocol is to improve team-based diagnostic decision making by focusing on data analytics and informatics tools that improve collective information management. Methods To achieve this goal, we will identify the factors contributing to failures in team-based diagnostic decision making (aim 1), understand the barriers of using current health information technology tools for team collaboration (aim 2), and develop and evaluate a collaborative decision-making prototype that can improve team-based diagnostic decision making (aim 3). Results Between 2019 to 2020, we are collecting data for this study. The results are anticipated to be published between 2020 and 2021. Conclusions The results from this study can shed light on improving diagnostic decision making by incorporating diagnostics rationale from team members. We believe a positive direction to move forward in solving diagnostic errors is by incorporating all team members, and using informatics. International Registered Report Identifier (IRRID) DERR1-10.2196/16047
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Affiliation(s)
- Don Roosan
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, United States
| | - Anandi V Law
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, United States
| | - Mazharul Karim
- Western University of Health Sciences, College of Pharmacy, Pomona, CA, United States
| | - Moom Roosan
- Chapman University, School of Pharmacy, Irvine, CA, United States
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20
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Gao F, Sunyaev A. Context matters: A review of the determinant factors in the decision to adopt cloud computing in healthcare. INTERNATIONAL JOURNAL OF INFORMATION MANAGEMENT 2019. [DOI: 10.1016/j.ijinfomgt.2019.02.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Augustsson H, Churruca K, Braithwaite J. Re-energising the way we manage change in healthcare: the case for soft systems methodology and its application to evidence-based practice. BMC Health Serv Res 2019; 19:666. [PMID: 31521156 PMCID: PMC6744652 DOI: 10.1186/s12913-019-4508-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 09/03/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Updating, improving and spreading the evidence base for healthcare practices has proven to be a challenge of considerable magnitude - a wicked, multi-dimensional problem. There are many interlinked factors which determine how, why and whether any particular implementation effort or intervention succeeds. Soft Systems Methodology (SSM), strongly grounded in systems ideas and complexity science, offers a structured, yet flexible process for dealing with situations that are perceived as problematical and in need of improvement. The aim of this paper is to propose the use of SSM for managing change in healthcare by way of addressing some of the complexities. The aim is further to illustrate examples of how SSM has been used in healthcare and discuss the features of the methodology that we believe can be harnessed to improve healthcare. DISCUSSION SSM is particularly suited for tackling real world problems that are difficult to define and where stakeholders may have divergent views on the situation and the objectives of change. SSM engages stakeholders in a learning cycle including: finding out about the problematical situation, i.e. the context in which the problem exists, by developing a rich picture of the situation; defining it by developing conceptual models and comparing these with the real world; taking action to improve it by deciding on desirable and feasible improvements; and implementing these in an iterative manner. Although SSM has been widely used in other sectors, it has not been extensively used in healthcare. We make the case for applying SSM to implementation and improvement endeavours in healthcare using the example of getting clinicians at the hospital level to use evidence-based guidelines. CONCLUSION Applying SSM means taking account of the multi-dimensional nature of care settings, and dealing with entrenched and unique contexts, cultures and socio-political ecosystems - precisely those that manifest in healthcare. There are gains to be made in appreciating complexity and facilitating contextualization of interventions, and by approaching improvements in an iterative learning cycle.
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Affiliation(s)
- Hanna Augustsson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW, 2109, Australia.
| | - Kate Churruca
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW, 2109, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW, 2109, Australia
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22
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Grando A, Manataki A, Furniss SK, Duncan B, Solomon A, Kaufman D, Hirn S, Sunday R, Bouchereau J, Doebbeling B, Burton MM, Poterack KA, Miksch T, Helmers RA. Multi-Method Study of Electronic Health Records Workflows. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2018; 2018:498-507. [PMID: 30815090 PMCID: PMC6371265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
EHRs transform work practices in ways that enhance or impede the quality of care. There is a need for in-depth analysis of EHR workflows, particularly in complex clinical environments. We investigated EHR-basedpre-operative workflows by combining findings from 18 interviews, 7 days of observations, and process mining of EHR interactions from 31 personnel caring for 375 patients at one tertiary referral center. We provided high-definition descriptions of workflows and personnel roles. One third (32.2%) of the time with each patient was spent interacting with the EHR and 4.2% using paper-based artifacts. We also mined personnel social networks validating observed personnel's EHR-interactions. When comparing workflows between two similar pre-operative settings at different hospitals, we found significant differences in physical organization, patient workflow, roles, use of EHR, social networks and time efficiency. This study informs Mayo Clinic's enterprise-wide conversion to a single EHR and will guide before and after workflow comparisons.
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Affiliation(s)
- Adela Grando
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Areti Manataki
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Stephanie K Furniss
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Benjamin Duncan
- Department of Biomedical Informatics, Arizona State University, AZ, US
| | - Andrew Solomon
- Department of Biomedical Informatics, Arizona State University, AZ, US
| | - David Kaufman
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Sarah Hirn
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Robert Sunday
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Joanne Bouchereau
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Brad Doebbeling
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
- School for the Science of Healthcare Delivery, Arizona State University, AZ, US
| | - Matthew M Burton
- Department of Biomedical Informatics, Arizona State University, AZ, US
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | | | - Tim Miksch
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
| | - Richard A Helmers
- Office of Information and Knowledge Management, Mayo Clinic, Rochester, MN, US
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23
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Veinot TC, Senteio CR, Hanauer D, Lowery JC. Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis. J Am Med Inform Assoc 2018; 25:746-758. [PMID: 29025114 PMCID: PMC7646963 DOI: 10.1093/jamia/ocx085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/18/2017] [Accepted: 08/01/2017] [Indexed: 01/04/2023] Open
Abstract
Objective To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research. Materials and Methods We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research. Results The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process. Discussion The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations. Conclusion The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.
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Affiliation(s)
- Tiffany C Veinot
- School of Information and School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Charles R Senteio
- Department of Library and Information Science, School of Communication and Information, Rutgers University, New Brunswick, NJ, USA
| | - David Hanauer
- Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Julie C Lowery
- Center for Clinical Management, Research, VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA
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Abstract
OBJECTIVE Long-term care (LTC), residential care requiring 24-hour nursing services, plays an important role in the health care service delivery system. The purpose of this study was to identify the needed clinical information and information flow to support LTC Registered Nurses (RNs) in care collaboration and clinical decision making. METHODS This descriptive qualitative study combines direct observations and semistructured interviews, conducted at Alberta's LTC facilities between May 2014 and August 2015. The constant comparative method (CCM) of joint coding was used for data analysis. RESULTS Nine RNs from six LTC facilities participated in the study. The RN practice environment includes two essential RN information management aspects: information resources and information spaces. Ten commonly used information resources by RNs included: (1) RN-personal notes; (2) facility-specific templates/forms; (3) nursing processes/tasks; (4) paper-based resident profile; (5) daily care plans; (6) RN-notebooks; (7) medication administration records (MARs); (8) reporting software application (RAI-MDS); (9) people (care providers); and (10) references (i.e., books). Nurses used a combination of shared information spaces, such as the Nurses Station or RN-notebook, and personal information spaces, such as personal notebooks or "sticky" notes. Four essential RN information management functions were identified: collection, classification, storage, and distribution. Six sets of information were necessary to perform RN care tasks and communication, including: (1) admission, discharge, and transfer (ADT); (2) assessment; (3) care plan; (4) intervention (with two subsets: medication and care procedure); (5) report; and (6) reference. Based on the RN information management system requirements, a graphic information flow model was constructed. CONCLUSION This baseline study identified key components of a current LTC nursing information management system. The information flow model may assist health information technology (HIT) developers to consolidate the design of HIT solutions for LTC, and serve as a communication tool between nurses and information technology (IT) staff to refine requirements and support further LTC HIT research.
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Affiliation(s)
- Quan Wei
- Alberta Health Services, Calgary, Alberta, Canada
| | - Karen L Courtney
- School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada
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25
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Grando A, Groat D, Furniss SK, Nowak J, Gaines R, Kaufman DR, Poterack KA, Miksch T, Helmers RA. Using Process Mining Techniques to Study Workflows in a Pre-operative Setting. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2018; 2017:790-799. [PMID: 29854145 PMCID: PMC5977611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Information technologies have transformed healthcare delivery and promise to improve efficiency and quality of care. However, in-depth analysis of EHR-mediated workflows is challenging. Our goal was to apply process mining, in combination with observational techniques, to understand EHR-based workflows. We reviewed nearly 76,000 event logs from 15 providers and supporting staff, and 142 patients in a pre-operative setting and we inspected 3 weeks of interviews and video observations. We found that on average 44 minutes were spent per patient interacting with the EHR, 55% of the time of the patient visit was spent by personnel interacting with the EHR and for over 5% of the time personnel used or reviewed paper-based artifacts. We also discovered the handover-of-care network and compared frequency of interactions between personnel. This study suggests that applying process mining in combination with observational techniques has vast potential for informing Mayo Clinic in the forthcoming EHR conversion.
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Affiliation(s)
- Adela Grando
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
| | - Danielle Groat
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
| | - Stephanie K Furniss
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
- Mayo Clinic, Rochester, MN
| | - Joshua Nowak
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
- Department of Biomedical Engineering, Arizona State University, Phoenix, AZ
| | - Regina Gaines
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
| | - David R Kaufman
- Department of Biomedical Informatics, Arizona State University, Phoenix, AZ
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26
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Abstract
BACKGROUND Care coordinators (CCs) are increasingly employed in primary care as a means to improve health care quality, but little research examines the process by which CCs are integrated into practices. This case study provides an in-depth examination of this process and efforts to optimize the role. METHODS Two CCs' work was observed and assessed, and attempts were made to optimize the role using workflow modeling and "Plan-Do-Study-Act" cycles. Rolling qualitative analyses of field notes from key informant interviews and team meetings were conducted using iterative cycles of "immersion/crystallization" to identify emerging themes. RESULTS Expected roles of CCs included case management of high-risk patients, transitions of care, and population management. Case management was the least difficult to implement; transition management required more effort; and population management met with individual and institutional obstacles and was difficult to address. CONCLUSIONS The process by which CCs are integrated into primary care is not well understood and will require more attention to optimally use this role to improve health care quality. Understanding aspects of CCs' roles that are the least and most difficult to integrate may provide a starting place for developing best practices for implementation of this emerging role.
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27
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Chen Y, Kho AN, Liebovitz D, Ivory C, Osmundson S, Bian J, Malin BA. Learning bundled care opportunities from electronic medical records. J Biomed Inform 2018; 77:1-10. [PMID: 29174994 PMCID: PMC5771885 DOI: 10.1016/j.jbi.2017.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/30/2017] [Accepted: 11/21/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The traditional fee-for-service approach to healthcare can lead to the management of a patient's conditions in a siloed manner, inducing various negative consequences. It has been recognized that a bundled approach to healthcare - one that manages a collection of health conditions together - may enable greater efficacy and cost savings. However, it is not always evident which sets of conditions should be managed in a bundled manner. In this study, we investigate if a data-driven approach can automatically learn potential bundles. METHODS We designed a framework to infer health condition collections (HCCs) based on the similarity of their clinical workflows, according to electronic medical record (EMR) utilization. We evaluated the framework with data from over 16,500 inpatient stays from Northwestern Memorial Hospital in Chicago, Illinois. The plausibility of the inferred HCCs for bundled care was assessed through an online survey of a panel of five experts, whose responses were analyzed via an analysis of variance (ANOVA) at a 95% confidence level. We further assessed the face validity of the HCCs using evidence in the published literature. RESULTS The framework inferred four HCCs, indicative of (1) fetal abnormalities, (2) late pregnancies, (3) prostate problems, and (4) chronic diseases, with congestive heart failure featuring prominently. Each HCC was substantiated with evidence in the literature and was deemed plausible for bundled care by the experts at a statistically significant level. CONCLUSIONS The findings suggest that an automated EMR data-driven framework conducted can provide a basis for discovering bundled care opportunities. Still, translating such findings into actual care management will require further refinement, implementation, and evaluation.
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Affiliation(s)
- You Chen
- Dept. of Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA.
| | - Abel N Kho
- Institute for Public Health and Medicine, Northwestern University, Chicago, IL, USA
| | | | - Catherine Ivory
- School of Nursing, Vanderbilt University, Nashville, TN, USA
| | - Sarah Osmundson
- Dept. of Obstetrics and Gynecology, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Jiang Bian
- Dept. of Health Outcomes and Policy, University of Florida, Gainesville, FL, USA
| | - Bradley A Malin
- Dept. of Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA; Dept. of Biostatistics, School of Medicine, Vanderbilt University, Nashville, TN, USA; Dept. of Electrical Engineering & Computer Science, School of Engineering, Vanderbilt University, Nashville, TN, USA
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Campion TR, Weinberg ST, Lorenzi NM, Waitman LR. Evaluation of Computerized Free Text Sign-Out Notes: Baseline Understanding and Recommendations. Appl Clin Inform 2017; 1:304-317. [PMID: 21258575 DOI: 10.4338/aci-2010-04-ra-0023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND: Standardization of sign-out, the transfer of patient information and responsibility between inpatient providers at shift change, is a Joint Commission National Patient Safety Goal intended to improve communication and reduce risk of error. Computerized systems with free text data entry and limited structure allow clinicians to generate sign-out notes in a variety of ways. OBJECTIVES: The literature lacks a systematic exploration of the range of content generated by users of computerized sign-out systems. The goal of this study was to determine if and how clinicians record standardized sign-out information using a system with free text data entry and limited structure. METHODS: Using qualitative methods, we reviewed free text sign-out notes for 730 patient cases across 39 hospital units at an academic medical center. RESULTS: Two categories of information expression emerged from analysis: patient treatment-comprised of patient summaries, awareness items, and action items-and care team coordination-consisting of discharge information, contact information, and social concerns. A third category describing the format of sign-out note content, presentation of information, also emerged. Location and structure of information varied, but sign-out note content for some hospital units exhibited specific characteristics and was relatively standardized. CONCLUSIONS: Findings provide a baseline understanding of computerized free text sign-out note content. Sign-out notes contained a synthesis of data from disparate sources. We recommend formalizing existing unit-specific content standardization and system use patterns to reduce sign-out note variability and improve communication.
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Affiliation(s)
- Thomas R Campion
- Vanderbilt University School of Medicine, Department of Biomedical Informatics
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29
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Ozkaynak M, Valdez R, Holden RJ, Weiss J. Infinicare framework for integrated understanding of health-related activities in clinical and daily-living contexts. Health Syst (Basingstoke) 2017; 7:66-78. [PMID: 31214339 PMCID: PMC6452830 DOI: 10.1080/20476965.2017.1390060] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 12/19/2016] [Accepted: 04/21/2017] [Indexed: 10/18/2022] Open
Abstract
Clinical and consumer health informatics interventions promise to transform health care, yielding higher quality, more accessible care at a lower cost. However, the potential of these interventions cannot be achieved if they are developed and rolled out in a disconnected way: clinic-based systems typically do not interface with home-based systems that capture patient-generated health-related data. The fragmentation between these interventions severely limits the benefits of all interventions; given that health care is a continuum between clinical and daily-living settings. We introduce the Infinicare framework, which posits that clinical health-related activities "shape" daily-living-based health-related activities and, conversely, that daily-living-based health-related activities "inform" activities in clinics. Non-alignment of activities across these diverse contexts yields systemic gaps. Workflow studies that capture health-related activities and characterise gaps between clinical and daily-living contexts can inform the design and implementation of gap-filling, collaborative health information technologies. To inform these technologies, workflow studies should be patient-oriented, include both clinical and daily-living settings and subsume both process and structure variables. Novel methodologies are needed to effectively and efficiently capture health-related activities across both clinical and daily-living settings and their contexts. Guidelines for applying these recommendations in developing collaborative health information technologies are provided.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, University of Colorado-Denver, Aurora, CO, USA
| | - Rupa Valdez
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Richard J. Holden
- Department of BioHealth Informatics, Indiana University School of Informatics and Computing, Indianapolis, IN, USA
| | - Jason Weiss
- College of Nursing, University of Colorado-Denver, Aurora, CO, USA
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Application of SSM in tackling problematical situations from academicians’ viewpoints. SYSTEMIC PRACTICE AND ACTION RESEARCH 2017. [DOI: 10.1007/s11213-017-9422-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Abstract
Objective Variations in processes for different clinics and health systems can dramatically change the way preventive interventions are implemented. We present a method for documenting these variations using workflow diagrams and demonstrate how understanding workflow aided an electronic health record (EHR) embedded colorectal cancer screening intervention. Materials and Methods We mapped variation in processes for ordering and documenting fecal testing, current colonoscopy, prior colonoscopies, and pathology results. This work was part of a multi-site cluster-randomized pragmatic trial to test a mailed approach to offering fecal testing at 26 safety net clinics (in eight organizations) in Oregon and Northern California. We created clinic-specific workflow diagrams and then distilled them into consolidated diagrams that captured the variations. Results Clinics had varied practices for storing and using information about colorectal cancer screening. Developing workflow diagrams of key processes enabled clinics to find optimal ways to send fecal test kits to patients due for screening. The workflows informed the rollout of new EHR tools and identified best practices for data capture. Discussion Diagramming workflows can have great utility when implementing and refining EHR tools for clinical practice, especially when doing so across multiple clinical sites. The process of developing the workflows uncovered successful practice recommendations and revealed limitations and potential effects of a research intervention. Conclusion Our method of documenting clinical process variation might inform other EHR-powered, multi-site research and can improve data feedback from EHR systems to clinical caregivers.
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Chung J, Ozkaynak M, Demiris G. Examining daily activity routines of older adults using workflow. J Biomed Inform 2017; 71:82-90. [PMID: 28529189 DOI: 10.1016/j.jbi.2017.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/14/2017] [Accepted: 05/15/2017] [Indexed: 11/29/2022]
Abstract
We evaluated the value of workflow analysis supported by a novel visualization technique to better understand the daily routines of older adults and highlight their patterns of daily activities and normal variability in physical functions. We used a self-reported activity diary to obtain data from six community-dwelling older adults for 14 consecutive days. Workflow for daily routine was analyzed using the EventFlow tool, which aggregates workflow information to highlight patterns and variabilities. A total of 1453 events were included in the data analysis. To demonstrate the patterns and variability of each individual's daily activities, participant activity workflows were visualized and compared. The workflow analysis revealed great variability in activity types, regularity, frequency, duration, and timing of performing certain activities across individuals. Also, when workflow approach was applied to spatial information of activities, the analysis revealed the ability to provide meaningful data on individuals' mobility in different levels of life spaces from home to community. Results suggest that using workflows to characterize the daily activities of older adults will be helpful for clinicians and researchers in understanding their daily routines and preparing education and prevention strategies tailored to each individual's activity level. This tool also has the potential to be integrated into consumer informatics technologies, such as patient portals or personal health records, so that consumers may be encouraged to become actively involved in monitoring and managing their health.
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Affiliation(s)
- Jane Chung
- College of Nursing, University of New Mexico, Albuquerque, NM 87131, USA.
| | - Mustafa Ozkaynak
- College of Nursing, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO 80045, USA
| | - George Demiris
- School of Nursing, University of Washington, Seattle, WA 98105, USA
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33
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Rucker DW. Using telephony data to facilitate discovery of clinical workflows. Appl Clin Inform 2017; 8:381-395. [PMID: 28421225 PMCID: PMC6241743 DOI: 10.4338/aci-2016-11-ra-0191] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 02/13/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Discovery of clinical workflows to target for redesign using methods such as Lean and Six Sigma is difficult. VoIP telephone call pattern analysis may complement direct observation and EMR-based tools in understanding clinical workflows at the enterprise level by allowing visualization of institutional telecommunications activity. OBJECTIVE To build an analytic framework mapping repetitive and high-volume telephone call patterns in a large medical center to their associated clinical units using an enterprise unified communications server log file and to support visualization of specific call patterns using graphical networks. METHODS Consecutive call detail records from the medical center's unified communications server were parsed to cross-correlate telephone call patterns and map associated phone numbers to a cost center dictionary. Hashed data structures were built to allow construction of edge and node files representing high volume call patterns for display with an open source graph network tool. RESULTS Summary statistics for an analysis of exactly one week's call detail records at a large academic medical center showed that 912,386 calls were placed with a total duration of 23,186 hours. Approximately half of all calling called number pairs had an average call duration under 60 seconds and of these the average call duration was 27 seconds. CONCLUSIONS Cross-correlation of phone calls identified by clinical cost center can be used to generate graphical displays of clinical enterprise communications. Many calls are short. The compact data transfers within short calls may serve as automation or re-design targets. The large absolute amount of time medical center employees were engaged in VoIP telecommunications suggests that analysis of telephone call patterns may offer additional insights into core clinical workflows.
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Affiliation(s)
- Donald W Rucker
- Donald W. Rucker, MD, 110 31st Avenue N, #406, Nashville, TN 37203, 617-834-5159, /
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34
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Wooldridge AR, Carayon P, Hundt AS, Hoonakker PLT. SEIPS-based process modeling in primary care. APPLIED ERGONOMICS 2017; 60:240-254. [PMID: 28166883 PMCID: PMC5308799 DOI: 10.1016/j.apergo.2016.11.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 11/09/2016] [Accepted: 11/18/2016] [Indexed: 05/14/2023]
Abstract
Process mapping, often used as part of the human factors and systems engineering approach to improve care delivery and outcomes, should be expanded to represent the complex, interconnected sociotechnical aspects of health care. Here, we propose a new sociotechnical process modeling method to describe and evaluate processes, using the SEIPS model as the conceptual framework. The method produces a process map and supplementary table, which identify work system barriers and facilitators. In this paper, we present a case study applying this method to three primary care processes. We used purposeful sampling to select staff (care managers, providers, nurses, administrators and patient access representatives) from two clinics to observe and interview. We show the proposed method can be used to understand and analyze healthcare processes systematically and identify specific areas of improvement. Future work is needed to assess usability and usefulness of the SEIPS-based process modeling method and further refine it.
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Affiliation(s)
- Abigail R Wooldridge
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, United States; Department of Industrial & Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States.
| | - Pascale Carayon
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, United States; Department of Industrial & Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Ann Schoofs Hundt
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, United States
| | - Peter L T Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, United States
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35
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Furniss SK, Burton MM, Grando A, Larson DW, Kaufman DR. Integrating Process Mining and Cognitive Analysis to Study EHR Workflow. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2017; 2016:580-589. [PMID: 28269854 PMCID: PMC5333235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
There are numerous methods to study workflow. However, few produce the kinds of in-depth analyses needed to understand EHR-mediated workflow. Here we investigated variations in clinicians' EHR workflow by integrating quantitative analysis of patterns of users' EHR-interactions with in-depth qualitative analysis of user performance. We characterized 6 clinicians' patterns of information-gathering using a sequential process-mining approach. The analysis revealed 519 different screen transition patterns performed across 1569 patient cases. No one pattern was followed for more than 10% of patient cases, the 15 most frequent patterns accounted for over half ofpatient cases (53%), and 27% of cases exhibited unique patterns. By triangulating quantitative and qualitative analyses, we found that participants' EHR-interactive behavior was associated with their routine processes, patient case complexity, and EHR default settings. The proposed approach has significant potential to inform resource allocation for observation and training. In-depth observations helped us to explain variation across users.
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Affiliation(s)
- Stephanie K Furniss
- Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ
| | - Matthew M Burton
- Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ; Office of Information and Knowledge Management
| | - Adela Grando
- Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David R Kaufman
- Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ
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Terry AL, Stewart M, Fortin M, Wong ST, Grava-Gubins I, Ashley L, Sullivan-Taylor P, Sullivan F, Zucker L, Thind A. Stepping Up to the Plate: An Agenda for Research and Policy Action on Electronic Medical Records in Canadian Primary Healthcare. Healthc Policy 2016; 12:19-32. [PMID: 28032822 PMCID: PMC5221709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Building on a previous study, which identified gaps in primary healthcare electronic medical record (emr) research and knowledge, a one-day conference was held to facilitate a strategic discussion of these issues. This paper offers a multi-faceted research agenda and suggestions for policy actions as a way forward in bridging the gaps. one facet focuses on the need for research. The second facet focuses on harnessing the knowledge of primary healthcare emr stakeholders. finally, the third facet focuses on policy actions. this paper offers consensus-based suggestions with a view to improving the overall primary healthcare emr landscape in canada.
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Affiliation(s)
- Amanda L. Terry
- Assistant Professor, Department of Family Medicine, Department of Epidemiology & Biostatistics, Schulich Interfaculty Program in Public Health, The University of Western Ontario, London, ON
| | - Moira Stewart
- Distinguished University Professor, Department of Family Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, ON
| | - Martin Fortin
- Professor, Department of Family Medicine, Université de Sherbrooke, Sherbrooke, QC
| | - Sabrina T. Wong
- Professor, UBC School of Nursing and Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC
| | | | - Lisa Ashley
- Senior Nurse Advisor, Canadian Nurses Association, Academic Consultant Level 2, School of Nursing, University of Ottawa, Ottawa, ON
| | - Patricia Sullivan-Taylor
- Director, Health System Funding Policy, Ontario Ministry of Health and Long-Term Care, Toronto, ON
| | - Frank Sullivan
- Gordon F. Cheesbrough Research Chair and Director of UTOPIAN, Professor, Department of Family & Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Lynne Zucker
- Vice President, Clinical Systems Integration, Canada Health Infoway, Toronto, ON
| | - Amardeep Thind
- Professor, Department of Family Medicine, Department of Epidemiology & Biostatistics, Director, Schulich Interfaculty Program in Public Health, The University of Western Ontario, London, ON
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Price M. Circle of care modelling: an approach to assist in reasoning about healthcare change using a patient-centric system. BMC Health Serv Res 2016; 16:546. [PMID: 27716188 PMCID: PMC5050584 DOI: 10.1186/s12913-016-1806-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 09/29/2016] [Indexed: 11/23/2022] Open
Abstract
Background Many health system and health Information and Communication Technology (ICT) projects do not achieve their expected benefits. This paper presents an approach to exploring changes in the healthcare system to better understand the expected improvements and other changes by using a patient-centric modelling approach. Circle of care modeling (CCM) was designed to assist stakeholders in considering healthcare system changes using a patient centric approach. Methods The CCM approach is described. It includes four steps, based on soft systems methodology: finding out, conceptual modelling, structured discussion, and describing potential improvements. There are four visualizations that are used though this process: patient-persona based rich pictures of care flows (as part of finding out), and three models: provider view, communication view, and information repository view (as part of conceptual modelling). Results Three case studies are presented where CCM was applied to different real-world healthcare problems: 1. Seeking improvements in continuity of care for end of life patients. 2. Exploring current practices for medication communication for ambulatory patients prior to an update of a jurisdictional drug information system. 3. Deciding how to improve attachment of patients to primary care. The cases illustrate how CCM helped stakeholders reason from a patient centered approach about gaps and improvements in care such as: data fragmentation (in 1), coordination efforts of medication management (in 2), and deciding to support a community health centre for unattached patients (in 3). Discussion The circle of care modelling approach has proved to be a useful tool in assisting stakeholders explore health system change in a patient centric approach. It is one way to instantiate the important principle of being patient centered into practice when considering health system changes.
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Affiliation(s)
- Morgan Price
- Island Medical Program, University of British Columbia, Vancouver, Canada. .,Department of Family Practice, Medical Science Building, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada.
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Wooldridge AR, Carayon P, Hoonakker P, Musa A, Bain P. Technology-Mediated Communication between Patients and Primary Care Clinicians and Staff. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/1541931213601128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Health information technology, i.e. secure messaging, can support high-quality, efficient care. Secure messaging – encrypted communication between patient and clinician or staff, similar to email – can facilitate patient-reported information and communication, but its fit with clinical workflow is not understood. Fifteen primary care clinicians and staff were interviewed and observed over 35 hours to understand the impact of secure messaging on ambiguity within the care delivery workflow. We developed a general workflow diagram for secure messaging, and identified three types of ambiguity relating to workflow, content of communication, and multiple points of data entry. While the use of secure messaging can help to clarify and document patient information, it can also increase ambiguity, particularly relating to the organization of work and workflow. Understanding how to design and implement technology to support multiple stakeholders, including patients, while considering the work system is a major area for future research.
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Affiliation(s)
- Abigail R. Wooldridge
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI
| | - Peter Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI
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Percival J, McGregor C. An Evaluation of Understandability of Patient Journey Models in Mental Health. JMIR Hum Factors 2016; 3:e20. [PMID: 27471006 PMCID: PMC4981695 DOI: 10.2196/humanfactors.5640] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/01/2016] [Accepted: 07/04/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is a significant trend toward implementing health information technology to reduce administrative costs and improve patient care. Unfortunately, little awareness exists of the challenges of integrating information systems with existing clinical practice. The systematic integration of clinical processes with information system and health information technology can benefit the patients, staff, and the delivery of care. OBJECTIVES This paper presents a comparison of the degree of understandability of patient journey models. In particular, the authors demonstrate the value of a relatively new patient journey modeling technique called the Patient Journey Modeling Architecture (PaJMa) when compared with traditional manufacturing based process modeling tools. The paper also presents results from a small pilot case study that compared the usability of 5 modeling approaches in a mental health care environment. METHOD Five business process modeling techniques were used to represent a selected patient journey. A mix of both qualitative and quantitative methods was used to evaluate these models. Techniques included a focus group and survey to measure usability of the various models. RESULTS The preliminary evaluation of the usability of the 5 modeling techniques has shown increased staff understanding of the representation of their processes and activities when presented with the models. Improved individual role identification throughout the models was also observed. The extended version of the PaJMa methodology provided the most clarity of information flows for clinicians. CONCLUSIONS The extended version of PaJMa provided a significant improvement in the ease of interpretation for clinicians and increased the engagement with the modeling process. The use of color and its effectiveness in distinguishing the representation of roles was a key feature of the framework not present in other modeling approaches. Future research should focus on extending the pilot case study to a more diversified group of clinicians and health care support workers.
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Affiliation(s)
- Jennifer Percival
- University of Ontario Institute of Technology, Faculty of Business and Information Technology, Oshawa, ON, Canada.
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Huang YH, Gramopadhye AK. Recommendations for health information technology implementation in rural hospitals. Int J Health Care Qual Assur 2016; 29:454-74. [DOI: 10.1108/ijhcqa-09-2015-0115] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– The purpose of this paper is to investigate violations against work standards associated with using a new health information technology (HIT) system. Relevant recommendations for implementing HIT in rural hospitals are provided and discussed to achieve meaningful use.
Design/methodology/approach
– An observational study is conducted to map medication administration process while using a HIT system in a rural hospital. Follow-up focus groups are held to determine and verify potential adverse factors related to using the HIT system while passing drugs to patients.
Findings
– A detailed task analysis demonstrated several violations, such as only relying on the barcode scanning system to match up with patient and drugs could potentially result in the medical staff forgetting to provide drug information verbally before administering drugs. There was also a lack of regulated and clear work procedure in using the new HIT system. In addition, the computer system controls and displays could not be adjusted so as to satisfy the users’ expectations. Nurses prepared medications and documentation in an environment that was prone to interruptions.
Originality/value
– Recommendations for implementing a HIT system in rural healthcare facilities can be categorized into five areas: people, tasks, tools, environment, and organization. Detailed remedial measures are provided for achieving continuous process improvements at resource-limited healthcare facilities in rural areas.
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Lesselroth BJ, Adams K, Tallett S, Wood SD, Keeling A, Cheng K, Church VL, Felder R, Tran H. Design of admission medication reconciliation technology: a human factors approach to requirements and prototyping. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2016; 6:30-48. [PMID: 23817905 DOI: 10.1177/193758671300600304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Our objectives were to (1) develop an in-depth understanding of the workflow and information flow in medication reconciliation, and (2) design medication reconciliation support technology using a combination of rapid-cycle prototyping and human-centered design. BACKGROUND Although medication reconciliation is a national patient safety goal, limitations both of physical environment and in workflow can make it challenging to implement durable systems. We used several human factors techniques to gather requirements and develop a new process to collect a medication history at hospital admission. METHODS We completed an ethnography and time and motion analysis of pharmacists in order to illustrate the processes used to reconcile medications. We then used the requirements to design prototype multimedia software for collecting a bedside medication history. We observed how pharmacists incorporated the technology into their physical environment and documented usability issues. RESULTS Admissions occurred in three phases: (1) list compilation, (2) order processing, and (3) team coordination. Current medication reconciliation processes at the hospital average 19 minutes to complete and do not include a bedside interview. Use of our technology during a bedside interview required an average of 29 minutes. The software represents a viable proof-of-concept to automate parts of history collection and enhance patient communication. However, we discovered several usability issues that require attention. CONCLUSIONS We designed a patient-centered technology to enhance how clinicians collect a patient's medication history. By using multiple human factors methods, our research team identified system themes and design constraints that influence the quality of the medication reconciliation process and implementation effectiveness of new technology. KEYWORDS Evidence-based design, human factors, patient-centered care, safety, technology.
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Affiliation(s)
- Blake J Lesselroth
- CORRESPONDING AUTHOR: Blake J. Lesselroth, MD MBI FACP; Director, Portland Patient Safety Center of Inquiry; Portland VA Medical Center, Department of Medicine; Mail Code: P3 MED; 3720 SW US Veterans Hospital Drive; Portland, Oregon, 97239; ; (503) 220-8262, ext. 55998; fax (503) 721-7807
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Steitz BD, Weinberg ST, Danciu I, Unertl KM. Managing and Communicating Operational Workflow: Designing and Implementing an Electronic Outpatient Whiteboard. Appl Clin Inform 2016; 7:59-68. [PMID: 27081407 DOI: 10.4338/aci-2015-07-cr-0082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 12/06/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Healthcare team members in emergency department contexts have used electronic whiteboard solutions to help manage operational workflow for many years. Ambulatory clinic settings have highly complex operational workflow, but are still limited in electronic assistance to communicate and coordinate work activities. OBJECTIVE To describe and discuss the design, implementation, use, and ongoing evolution of a coordination and collaboration tool supporting ambulatory clinic operational workflow at Vanderbilt University Medical Center (VUMC). METHODS The outpatient whiteboard tool was initially designed to support healthcare work related to an electronic chemotherapy order-entry application. After a highly successful initial implementation in an oncology context, a high demand emerged across the organization for the outpatient whiteboard implementation. Over the past 10 years, developers have followed an iterative user-centered design process to evolve the tool. RESULTS The electronic outpatient whiteboard system supports 194 separate whiteboards and is accessed by over 2800 distinct users on a typical day. Clinics can configure their whiteboards to support unique workflow elements. Since initial release, features such as immunization clinical decision support have been integrated into the system, based on requests from end users. CONCLUSIONS The success of the electronic outpatient whiteboard demonstrates the usefulness of an operational workflow tool within the ambulatory clinic setting. Operational workflow tools can play a significant role in supporting coordination, collaboration, and teamwork in ambulatory healthcare settings.
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Affiliation(s)
- Bryan D Steitz
- Department of Biomedical Informatics, Vanderbilt University School of Medicine
| | - Stuart T Weinberg
- Department of Biomedical Informatics, Vanderbilt University School of Medicine; Department of Pediatrics, Vanderbilt University School of Medicine
| | - Ioana Danciu
- Department of Biomedical Informatics, Vanderbilt University School of Medicine; Department of Quality Safety and Risk Prevention, Vanderbilt University Medical Center
| | - Kim M Unertl
- Department of Biomedical Informatics, Vanderbilt University School of Medicine
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Alhuwail D, Koru G. Identifying Home Care Clinicians' Information Needs for Managing Fall Risks. Appl Clin Inform 2016; 7:211-26. [PMID: 27437035 PMCID: PMC4941834 DOI: 10.4338/aci-2015-11-ra-0160] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 01/26/2016] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To help manage the risk of falls in home care, this study aimed to (i) identify home care clinicians' information needs and how they manage missing or inaccurate data, (ii) identify problems that impact effectiveness and efficiency associated with retaining, exchanging, or processing information about fall risks in existing workflows and currently adopted health information technology (IT) solutions, and (iii) offer informatics-based recommendations to improve fall risk management interventions. METHODS A case study was carried out in a single not-for-profit suburban Medicare-certified home health agency with three branches. Qualitative data were collected over a six month period through observations, semi-structured interviews, and focus groups. The Framework method was used for analysis. Maximum variation sampling was adopted to recruit a diverse sample of clinicians. RESULTS Overall, the information needs for fall risk management were categorized into physiological, care delivery, educational, social, environmental, and administrative domains. Examples include a brief fall-related patient history, weight-bearing status, medications that affect balance, availability of caregivers at home, and the influence of patients' cultures on fall management interventions. The unavailability and inaccuracy of critical information related to fall risks can delay necessary therapeutic services aimed at reducing patients' risk for falling and thereby jeopardizing their safety. Currently adopted IT solutions did not adequately accommodate data related to fall risk management. CONCLUSION The results highlight the essential information for fall risk management in home care. Home care workflows and health IT solutions must effectively and efficiently retain, exchange, and process information necessary for fall risk management. Interoperability and integration of the various health IT solutions to make data sharing accessible to all clinicians is critical for fall risk management. Findings from this study can help home health agencies better understand their information needs to manage fall risks.
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Affiliation(s)
- Dari Alhuwail
- Department of Information Systems, University of Maryland, Baltimore County
| | - Güneş Koru
- Department of Information Systems, University of Maryland, Baltimore County
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Ferrante S, Bonacina S, Pozzi G, Pinciroli F, Marceglia S. A Design Methodology for Medical Processes. Appl Clin Inform 2016; 7:191-210. [PMID: 27081415 DOI: 10.4338/aci-2015-08-ra-0111] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 01/24/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Healthcare processes, especially those belonging to the clinical domain, are acknowledged as complex and characterized by the dynamic nature of the diagnosis, the variability of the decisions made by experts driven by their experiences, the local constraints, the patient's needs, the uncertainty of the patient's response, and the indeterminacy of patient's compliance to treatment. Also, the multiple actors involved in patient's care need clear and transparent communication to ensure care coordination. OBJECTIVES In this paper, we propose a methodology to model healthcare processes in order to break out complexity and provide transparency. METHODS The model is grounded on a set of requirements that make the healthcare domain unique with respect to other knowledge domains. The modeling methodology is based on three main phases: the study of the environmental context, the conceptual modeling, and the logical modeling. RESULTS The proposed methodology was validated by applying it to the case study of the rehabilitation process of stroke patients in the specific setting of a specialized rehabilitation center. The resulting model was used to define the specifications of a software artifact for the digital administration and collection of assessment tests that was also implemented. CONCLUSIONS Despite being only an example, our case study showed the ability of process modeling to answer the actual needs in healthcare practices. Independently from the medical domain in which the modeling effort is done, the proposed methodology is useful to create high-quality models, and to detect and take into account relevant and tricky situations that can occur during process execution.
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Affiliation(s)
- Simona Ferrante
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano , Milano, Italy
| | - Stefano Bonacina
- Health Informatics Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet , Stockholm, Sweden
| | - Giuseppe Pozzi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano , Milano, Italy
| | - Francesco Pinciroli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy; Engineering in Health and Wellbeing Research Group at the National Research Council of Italy IEIIT - Istituto di Elettronica e di Ingegneria dell'Informazione e delle Telecomunicazioni, Trieste, Italy
| | - Sara Marceglia
- Dipartimento di Ingegneria e Architettura, Università degli Studi di Trieste, Trieste, Italy; Clinical Center for Neurostimulation, Neurotechnology, and Movement Disorders Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milano, Italy
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Javan Amoli AH, Maserat E, Safdari R, Zali MR. Electronic Risk Assessment System as an Appropriate Tool for the Prevention of Cancer: a Qualitative Study. Asian Pac J Cancer Prev 2016; 16:8595-8. [PMID: 26745122 DOI: 10.7314/apjcp.2015.16.18.8595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decision making modalities for screening for many cancer conditions and different stages have become increasingly complex. Computer-based risk assessment systems facilitate scheduling and decision making and support the delivery of cancer screening services. The aim of this article was to survey electronic risk assessment system as an appropriate tool for the prevention of cancer. MATERIALS AND METHODS A qualitative design was used involving 21 face-to-face interviews. Interviewing involved asking questions and getting answers from exclusive managers of cancer screening. Of the participants 6 were female and 15 were male, and ages ranged from 32 to 78 years. The study was based on a grounded theory approach and the tool was a semi- structured interview. RESULTS Researchers studied 5 dimensions, comprising electronic guideline standards of colorectal cancer screening, work flow of clinical and genetic activities, pathways of colorectal cancer screening and functionality of computer based guidelines and barriers. Electronic guideline standards of colorectal cancer screening were described in the s3 categories of content standard, telecommunications and technical standards and nomenclature and classification standards. According to the participations' views, workflow and genetic pathways of colorectal cancer screening were identified. CONCLUSIONS The study demonstrated an effective role of computer-guided consultation for screening management. Electronic based systems facilitate real-time decision making during a clinical interaction. Electronic pathways have been applied for clinical and genetic decision support, workflow management, update recommendation and resource estimates. A suitable technical and clinical infrastructure is an integral part of clinical practice guidline of screening. As a conclusion, it is recommended to consider the necessity of architecture assessment and also integration standards.
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Chen Y, Xie W, Gunter CA, Liebovitz D, Mehrotra S, Zhang H, Malin B. Inferring Clinical Workflow Efficiency via Electronic Medical Record Utilization. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2015; 2015:416-425. [PMID: 26958173 PMCID: PMC4765602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Complexity in clinical workflows can lead to inefficiency in making diagnoses, ineffectiveness of treatment plans and uninformed management of healthcare organizations (HCOs). Traditional strategies to manage workflow complexity are based on measuring the gaps between workflows defined by HCO administrators and the actual processes followed by staff in the clinic. However, existing methods tend to neglect the influences of EMR systems on the utilization of workflows, which could be leveraged to optimize workflows facilitated through the EMR. In this paper, we introduce a framework to infer clinical workflows through the utilization of an EMR and show how such workflows roughly partition into four types according to their efficiency. Our framework infers workflows at several levels of granularity through data mining technologies. We study four months of EMR event logs from a large medical center, including 16,569 inpatient stays, and illustrate that over approximately 95% of workflows are efficient and that 80% of patients are on such workflows. At the same time, we show that the remaining 5% of workflows may be inefficient due to a variety of factors, such as complex patients.
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Affiliation(s)
- You Chen
- Vanderbilt University, Nashville, TN
| | - Wei Xie
- Vanderbilt University, Nashville, TN
| | | | | | | | - He Zhang
- University of South Florida, Tampa, FL
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Eikey EV, Reddy MC, Kuziemsky CE. Examining the role of collaboration in studies of health information technologies in biomedical informatics: A systematic review of 25 years of research. J Biomed Inform 2015; 57:263-77. [DOI: 10.1016/j.jbi.2015.08.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 07/31/2015] [Accepted: 08/05/2015] [Indexed: 10/23/2022]
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Pivovarov R, Elhadad N. Automated methods for the summarization of electronic health records. J Am Med Inform Assoc 2015; 22:938-47. [PMID: 25882031 PMCID: PMC4986665 DOI: 10.1093/jamia/ocv032] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/15/2015] [Indexed: 02/02/2023] Open
Abstract
Objectives This review examines work on automated summarization of electronic health record (EHR) data and in particular, individual patient record summarization. We organize the published research and highlight methodological challenges in the area of EHR summarization implementation. Target audience The target audience for this review includes researchers, designers, and informaticians who are concerned about the problem of information overload in the clinical setting as well as both users and developers of clinical summarization systems. Scope Automated summarization has been a long-studied subject in the fields of natural language processing and human–computer interaction, but the translation of summarization and visualization methods to the complexity of the clinical workflow is slow moving. We assess work in aggregating and visualizing patient information with a particular focus on methods for detecting and removing redundancy, describing temporality, determining salience, accounting for missing data, and taking advantage of encoded clinical knowledge. We identify and discuss open challenges critical to the implementation and use of robust EHR summarization systems.
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Affiliation(s)
- Rimma Pivovarov
- Department of Biomedical Informatics, Columbia University, New York, USA
| | - Noémie Elhadad
- Department of Biomedical Informatics, Columbia University, New York, USA
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Mensah N, Sukums F, Awine T, Meid A, Williams J, Akweongo P, Kaltschmidt J, Haefeli WE, Blank A. Impact of an electronic clinical decision support system on workflow in antenatal care: the QUALMAT eCDSS in rural health care facilities in Ghana and Tanzania. Glob Health Action 2015; 8:25756. [PMID: 25630707 PMCID: PMC4309829 DOI: 10.3402/gha.v8.25756] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/24/2014] [Accepted: 11/25/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The implementation of new technology can interrupt established workflows in health care settings. The Quality of Maternal Care (QUALMAT) project has introduced an electronic clinical decision support system (eCDSS) for antenatal care (ANC) and delivery in rural primary health care facilities in Africa. OBJECTIVE This study was carried out to investigate the influence of the QUALMAT eCDSS on the workflow of health care workers in rural primary health care facilities in Ghana and Tanzania. DESIGN A direct observation, time-and-motion study on ANC processes was conducted using a structured data sheet with predefined major task categories. The duration and sequence of tasks performed during ANC visits were observed, and changes after the implementation of the eCDSS were analyzed. RESULTS In 24 QUALMAT study sites, 214 observations of ANC visits (144 in Ghana, 70 in Tanzania) were carried out at baseline and 148 observations (104 in Ghana, 44 in Tanzania) after the software was implemented in 12 of those sites. The median time spent combined for all centers in both countries to provide ANC at baseline was 6.5 min [interquartile range (IQR) =4.0-10.6]. Although the time spent on ANC increased in Tanzania and Ghana after the eCDSS implementation as compared to baseline, overall there was no significant increase in time used for ANC activities (0.51 min, p=0.06 in Ghana; and 0.54 min, p=0.26 in Tanzania) as compared to the control sites without the eCDSS. The percentage of medical history taking in women who had subsequent examinations increased after eCDSS implementation from 58.2% (39/67) to 95.3% (61/64) p<0.001 in Ghana but not in Tanzania [from 65.4% (17/26) to 71.4% (15/21) p=0.70]. CONCLUSIONS The QUALMAT eCDSS does not increase the time needed for ANC but partly streamlined workflow at sites in Ghana, showing the potential of such a system to influence quality of care positively.
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Affiliation(s)
- Nathan Mensah
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany; Navrongo Health Research Centre, Navrongo, Ghana
| | - Felix Sukums
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany; Muhimbili University of Health and Allied Sciences (MUHAS), Directorate of Information and Communication Technology, Dar Es Salaam, Tanzania
| | | | - Andreas Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Jens Kaltschmidt
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany;
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Ajami S, Ahmadi G, Etemadifar M. The role of information system in multiple sclerosis management. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2014; 19:1175-84. [PMID: 25709660 PMCID: PMC4333527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Revised: 11/18/2013] [Accepted: 03/14/2014] [Indexed: 12/03/2022]
Abstract
Multiple sclerosis (MS) is a chronic disease of central nervous system. The multiple sclerosis information system (MSIS), such as other information system (IS), depends on identification, collection and processing of data for producing useful information. Lack of the integrated IS for collecting standard data causes undesirable effects on exchanging, comparing, and managing. The aim of this study was to recognize the role of the IS in the MS management and determine the advantages and barriers in implementing of the MSIS. The present study was a nonsystematized review that was done in order to recognize the role of the IS in the MS management. In this study, electronic scientific resources such as scientific magazines and books and published topics at conferences were used. We used key words (IS, chronic disease management, and multiple sclerosis), their combination or their synonyms in title, key words, abstracts, and text of English articles and published reports from 1980 until 2013, and by using search engines such as Google, Google Scholar and scientific databases and electronic issues such as iPubMed, sufficiently important difference, Scopus, Medlib, and Magiran for gathering information. More than 200 articles and reports were collected and assessed and 139 of them. Findings showed that the MSIS can reduce of disease expenses through continuously collecting correct, accurate, sufficient, and timely patients and disease nature information; recoding; editing; processing; exchanging, and distributing among different health care centers. Although the MSIS has many advantages; but, we cannot ignore cultural, economic, technical, organizational, and managerial barriers. Therefore, it is necessary to do studies for preventing, reducing, and controlling them. One of the ways is to recognize the advantages of the MSIS and usage information technology in optimizing disease management.
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Affiliation(s)
- Sima Ajami
- Department of Management and Health Information Technology, Health Management and Economics Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Golchehreh Ahmadi
- Department of Management and Health Information Technology, School of Medical Management and Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoud Etemadifar
- Department of Neurology, Director of MS Isfahan Clinic, Isfahan University of Medical Sciences, Isfahan, Iran
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