Using Visual Analytics to Determine the Utilization of Preoperative Anesthesia Assessments

Surgery and Anesthesia Preoperative "Virtual Huddle": A Pilot Trial to Enhance Communication across the Drape

OBJECTIVES

 Effective communication between surgeons and anesthesiologists is critical for high-quality, safe, and efficient perioperative patient care. Despite widespread implementation of surgical safety checklists and time-outs, ineffective team communication remains a leading cause of patient safety events in the operating room. To promote effective communication, we conducted a pilot trial of a "virtual huddle" between anesthesiologists and surgeons.

METHODS

 Attending anesthesiologists and surgeons at an academic medical center were recruited by email to participate in this feasibility trial. An electronic health record-based smartphone application was utilized to create secure group chats among trial participants the day before a surgery. Text notifications connected a surgeon/anesthesiologist pair in order to introduce colleagues, facilitate a preoperative virtual huddle, and enable open-ended, text message-based communication. A 5-point Likert scale-based survey with a free-text component was used to evaluate the utility of the virtual huddle and usability of the electronic platform.

RESULTS

 A total of 51 unique virtual huddles occurred between 16 surgeons and 12 anesthesiologists over 99 operations. All postintervention survey questions received a positive rating (range: 3.50/5.00-4.53/5.00) and the virtual huddle was considered to be easy to use (4.47/5.00), improve attending-to-attending communication (4.29/5.00), and improve patient care (4.22/5.00). There were no statistically significant differences in the ratings between surgery and anesthesia. In thematic analysis of qualitative survey results, Participants indicated the intervention was particularly useful in interdisciplinary relationship-building and reducing room turnover. The huddle was less useful for simple, routine cases or when participation was one sided.

CONCLUSION

 A preoperative virtual huddle may be a simple and effective intervention to improve communication and teamwork in the operating room. Further study and consideration of broader implementation is warranted.

Using electronic health record audit logs to study clinical activity: a systematic review of aims, measures, and methods

OBJECTIVE

To systematically review published literature and identify consistency and variation in the aims, measures, and methods of studies using electronic health record (EHR) audit logs to observe clinical activities.

MATERIALS AND METHODS

In July 2019, we searched PubMed for articles using EHR audit logs to study clinical activities. We coded and clustered the aims, measures, and methods of each article into recurring categories. We likewise extracted and summarized the methods used to validate measures derived from audit logs and limitations discussed of using audit logs for research.

RESULTS

Eighty-five articles met inclusion criteria. Study aims included examining EHR use, care team dynamics, and clinical workflows. Studies employed 6 key audit log measures: counts of actions captured by audit logs (eg, problem list viewed), counts of higher-level activities imputed by researchers (eg, chart review), activity durations, activity sequences, activity clusters, and EHR user networks. Methods used to preprocess audit logs varied, including how authors filtered extraneous actions, mapped actions to higher-level activities, and interpreted repeated actions or gaps in activity. Nineteen studies validated results (22%), but only 9 (11%) through direct observation, demonstrating varying levels of measure accuracy.

DISCUSSION

While originally designed to aid access control, EHR audit logs have been used to observe diverse clinical activities. However, most studies lack sufficient discussion of measure definition, calculation, and validation to support replication, comparison, and cross-study synthesis.

CONCLUSION

EHR audit logs have potential to scale observational research but the complexity of audit log measures necessitates greater methodological transparency and validated standards.

Decision-Centered Design of Patient Information Visualizations to Support Chronic Pain Care

BACKGROUND

For complex patients with chronic conditions, electronic health records (EHRs) contain large amounts of relevant historical patient data. To use this information effectively, clinicians may benefit from visual information displays that organize and help them make sense of information on past and current treatments, outcomes, and new treatment options. Unfortunately, few clinical decision support tools are designed to support clinical sensemaking.

OBJECTIVE

The objective of this study was to describe a decision-centered design process, and resultant interactive patient information displays, to support key clinical decision requirements in chronic noncancer pain care.

METHODS

To identify key clinical decision requirements, we conducted critical decision method interviews with 10 adult primary care clinicians. Next, to identify key information needs and decision support design seeds, we conducted a half-day multidisciplinary design workshop. Finally, we designed an interactive prototype to support the key clinical decision requirements and information needs uncovered during the previous research activities.

RESULTS

The resulting Chronic Pain Treatment Tracker prototype summarizes the current treatment plan, past treatment history, potential future treatments, and treatment options to be cautious about. Clinicians can access additional details about each treatment, current or past, through modal views. Additional decision support for potential future treatments and treatments to be cautious about is also provided through modal views.

CONCLUSION

This study designed the Chronic Pain Treatment Tracker, a novel approach to decision support that presents clinicians with the information they need in a structure that promotes quick uptake, understanding, and action.

A Visual Analytics Dashboard to Summarize Serial Anesthesia Records in Pediatric Radiation Treatment

BACKGROUND

Young children who undergo radiation therapy may require general anesthesia to remain still during weeks of radiation sessions. On a typical day at our hospital, an anesthesia team will care for 10 patients in the radiation therapy suite, and each patient will have multiple prior anesthetic records. Daily review of prior anesthesia records is important to maintain anesthetic consistency and to identify potential improvement, yet our electronic health record (EHR) made such review time-consuming and cumbersome.

OBJECTIVES

This article aims to design a visual analytics interface that simultaneously displays data from multiple anesthesia encounters to support clinical consistency in medications and airway management.

METHODS

Documentation from the EHR is available in the clinical data warehouse following daily backups. A visual analytics interface was built to aggregate important components of multiple anesthesia encounters in pediatric radiation oncology on a single screen. The application was embedded in the EHR's anesthesia module and updated daily.

RESULTS

Each anesthesia encounter was represented by a vertical line with the date at the bottom of the screen. Each vertical line was divided into sections corresponding to the medications, type of airway device, type of radiation oncology procedure, days between treatments, and recovery score and time. Information about the medications, airways, and procedures was shown with icon legends. This layout enabled users to quickly see the key components of multiple anesthetics and make inferences between, for example, the medications used and the recovery score.

CONCLUSION

The dashboard provides a high-level summary of all radiation therapy anesthesia records for children receiving recurrent treatments. In this clinical scenario, it is desirable to replicate an optimal anesthetic approach for daily or near-daily treatments or adjust the anesthetic based on observed patterns.

Quality Initiative Using Theory of Change and Visual Analytics to Improve Controlled Substance Documentation Discrepancies in the Operating Room

BACKGROUND

Discrepancies in controlled substance documentation are common and can lead to legal and regulatory repercussions. We introduced a visual analytics dashboard to assist in a quality improvement project to reduce the discrepancies in controlled substance documentation in the operating room (OR) of our free-standing pediatric hospital.

METHODS

Visual analytics were applied to collected documentation discrepancy audit data and were used to track progress of the project, to motivate the OR team, and in analyzing where further improvements could be made. This was part of a seven-step improvement plan based on the Theory of Change with a logic model framework approach.

RESULTS

The introduction of the visual analytics dashboard contributed a 24% improvement in controlled substance documentation discrepancy. The project overall reduced documentation errors by 71% over the studied period.

CONCLUSION

We used visual analytics to simultaneously analyze, monitor, and interpret vast amounts of data and present them in an appealing format. In conjunction with quality-improvement principles, this led to a significant improvement in controlled substance documentation discrepancies.

Ontology-Based Interactive Visualization of Patient-Generated Research Questions

BACKGROUND

Crohn's disease and colitis are chronic conditions that affect every facet of patients' lives (e.g., social interaction, family, work, diet, and sleep). Thus, treatment consists largely of disease management. The University of North Carolina at Chapel Hill chapter of the Crohn's and Colitis Foundation-IBD Partners-has created an interactive website that, in addition to providing helpful information and disease management tools, provides a discussion forum for patients to talk about their experiences and suggest new lines of research into Crohn's disease and colitis.

OBJECTIVES

The primary objective of this work is to enable researchers to more effectively browse the forum content. Researchers wish to identify important/popular patient-suggested research topics, appreciate the full breadth of the research topics, and see connections between them, in order to more effectively prioritize research agendas.

METHODS

To help structure the forum content we have developed an ontology describing the major themes in the discussion forum. We have also created a prototype interactive visualization tool that leverages the ontology to help researchers identify common themes and related patient-generated research topics via linked views of (1) the ontology, (2) a research topic overview clustered by relevant ontology terms, and (3) a detailed view of the discussion forum content.

RESULTS

We discuss visualizations and interactions enabled by the visualization tool, provide an example scenario using the tool, and discuss limitations and future work based on feedback from potential users.

CONCLUSION

The integration of a user-community specific ontology with an interactive visualization tool is a promising approach for enabling researchers to more effectively study user-generated research questions.

Provider Access to Legacy Electronic Anesthesia Records Following Implementation of an Electronic Health Record System

Many hospitals are in the process of replacing their legacy anesthesia information management system (AIMS) with an Electronic Health Record (EHR) system, within which the AIMS is integrated. Using the legacy AIMS security access log table, we studied the extent to which anesthesia providers were accessing historical anesthesia records (January 2006 - March 2017) following implementation of an EHR (April 2017). Statistical analysis was by segmented regression. At the time of implementation of the EHR, in 44.8% (SE = 0.3%) of cases, there was a prior anesthetic record for the patient that had been documented in the legacy AIMS. Following EHR implementation, the mean number of preoperative clinical views of all prior anesthetic records divided by the total number of cases performed decreased to 2.3% (0.3%) from the baseline of 25.1% (0.8%). The estimated ratio of the 2 means was 0.18 (95% CI 0.11 to 0.31, P < 0.00001). For views of unique records, the decrease was to 2.2% (0.3%) from the baseline of 18.3% (0.5%). The estimated ratio was 0.23 (95% CI 0.15 to 0.35, P < 0.00001). These results show that, following conversion to an integrated EHR, providing access to historical anesthesia records by maintaining the legacy AIMS is not an effective strategy to promote review of such records as part of the preoperative evaluation process. Because such records provide important information for many patients, providing linked access to such records within the EHR as part of the patient encounter may be a more effective approach.

Timely Data for Targeted Quality Improvement Interventions: Use of a Visual Analytics Dashboard for Bronchiolitis

BACKGROUND

Standard methods for obtaining data may delay quality improvement (QI) interventions including for bronchiolitis, a common cause of childhood hospitalization.

OBJECTIVE

To describe the use of a dashboard in the context of a multifaceted QI intervention aimed at reducing the use of chest radiographs, bronchodilators, antibiotics, steroids, and viral testing in patients with bronchiolitis.

METHODS

This QI initiative took place at Children's Minnesota, a large, not-for-profit children's health care organization. A multidisciplinary bronchiolitis workgroup developed a local clinical guideline and order-set. Delays in obtaining baseline data prompted a pediatric hospitalist and information technology specialist to modify a vendor's dashboard to display data related to bronchiolitis guideline metrics. Patients 2 months to 2 years old with a bronchiolitis emergency department (ED)/inpatient encounter in the period October 1, 2014 to April 30, 2018 were included. The primary outcome was a functioning dashboard; a process measure was the percentage of ED clinician logins. Outcome measures included the percent use of guideline metrics (e.g., bronchodilators) displayed on statistical process control charts (ED vs. inpatient). Balancing measures included length of stay, charge ratios, and hospital revisits.

RESULTS

A workgroup (formed October 2015) implemented a bronchiolitis order-set and guideline (February 2016) followed by a bronchiolitis dashboard (August 2016) consolidating disparate data sources loaded within 2 to 4 days of discharge. In total, 35% of ED clinicians logged in. Leaders used the dashboard to target and track interventions such as a bronchodilator order alert. There were improvements in most outcome metrics; however, timing did not suggest direct dashboard impact. ED balancing measures were lower after implementation.

CONCLUSION

We described use of a dashboard to support a multifaceted QI initiative for bronchiolitis. Leaders used the dashboard for targeted interventions but the dashboard did not directly impact the observed improvements. Future studies should assess reasons for low individual dashboard use.