Michael C. Gibbons

eHealth Solutions for Healthcare Disparities

Paralleling emerging trends in cyber-health technology, concerns are mounting about racial, ethnic, disparities in health care utilization and outcomes. eHealth Solutions for Health Care Disparities brings these currents together, challenging readers to use, promote, and develop new technology-based methods for closing these gaps. Edited by a leading urban health advocate and featuring 16 expert contributors, the book examines cyber-strategies with the greatest potential toward effective, equitable care, improved service delivery and better health outcomes for all. Chapters go well beyond the possibilities of the Electronic Medical Record to discuss emerging roles for information technology in promoting healthful behavior changes (e.g., nutrition, weight loss, smoking cessation), disease prevention (e.g., cancer, HIV), and healthcare utilization, patient education and medicine compliance). The rise of e-Patients and the transformation of the doctor-patient relationship are also discussed. Opportunities for Web based products and interventions are explored in terms of tracking disparities, improving healthcare utilization and health outcomes, reducing disparities and monitoring trends among patients, whether they have Internet capabilities or not.

Integrating Electronic Health Records into Clinical Workflow: An Application of Human Factors Modeling Methods to Ambulatory Care

Issues with workflow integration have contributed to slow rates of EHR adoption in ambulatory outpatient care settings. In response to workflow integration challenges with EHRs, clinicians often develop workarounds to complete clinical tasks in ways other than were intended by system designers. Based on the insights generated during collegial discussions with physician Subject Matter Experts (SMEs) and three interdisciplinary team meetings with clinical and human factors experts, we created process map visualizations. A wide range of opportunities to improve workflow through enhanced functionality with the EHR were identified. Targeted recommendations for EHR developers and ambulatory (outpatient) care centers are proposed to increase efficiency, allow for better eye contact between the physician and patient, improve physician’s information workflow, and reduce alert fatigue. These recommendations provide a first step in moving from a billing-centered perspective to a clinician-centered perspective.

Consumer health informatics: results of a systematic evidence review and evidence based recommendations

An increasing array of technology based tools are available for patient and consumer utilization which claim to facilitate health improvement. The efficacy of these Consumer Health Informatics tools has not previously been systematically reviewed. As such a systematic evidence review of the efficacy of consumer health informatics tools was conducted. This review also sought evidence of any barriers to future widespread utilization of these tools and evidence of economic impact of these tools on health care costs. The findings of this review indicate that while more work needs to be done, the available literature does suggest a positive impact of consumer health informatics tools on select health conditions and outcomes. Many barriers remain that must be overcome prior to widespread utilization of these tools. There was insufficient data regarding economic impact of consumer health informatics tools on healthcare costs.

Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of Columbia

Rationale PROTECT DC examines whether stroke navigators can improve cardiovascular risk factors in urban underserved individuals newly hospitalized for stroke or ischemic attack. Within one-year of hospital discharge, up to one-third of patients no longer adhere to secondary prevention behaviors. Adherence rates are lower in minority-underserved groups, contributing to health disparities. In-hospital programs increase use of stroke prevention therapies but may not be as successful in underserved individuals. In these groups, low literacy, limited healthcare access, and sparse community resources may reduce adherence. Lay community health workers (navigators) improve adherence in other illnesses through education and assisting in overcoming barriers to achieving desired health behaviors and obtaining needed healthcare services. Aims and design PROTECT DC is a Phase II, single-blind, randomized, controlled trial comparing in-hospital education plus stroke navigators to usual care. Atherogenic ischemic stroke and transient ischemic attack survivors are recruited from Washington, DC hospitals. Navigators meet with participants during the index hospitalization, perform home visits, and meet by phone. They focus on stroke education, medication compliance, and overcoming practical barriers to adherence. The interventions are driven by the theories of reasoned action and planned behavior. Study outcomes The primary dependent measure is a summary score of four objective measures of stroke risk factor control: systolic blood pressure, low-density lipoprotein, hemoglobin Hb A1C, and antiplatelet agent pill counts. Secondary outcomes include stroke knowledge, exercise, dietary modification, and smoking cessation. Conclusion PROTECT DC will determine whether a Phase III trial of stroke navigation for urban underserved individuals to improve adherence to secondary stroke prevention behaviors is warranted.

Enhancing Electronic Health Record Usability in Pediatric Patient Care: A Scenario-Based Approach

BACKGROUND Usability of electronic health records (EHRs) is an important factor affecting patient safety and the EHR adoption rate for both adult and pediatric care providers. A panel of interdisciplinary experts (the authors) was convened by the National Institute of Standards and Technology to generate consensus recommendations to improve EHR usefulness, usability, and patient safety when supporting pediatric care, with a focus on critical user interactions. METHODS The panel members represented expertise in the disciplines of human factors engineering (HFE), usability, informatics, and pediatrics in ambulatory care and pediatric intensive care. An iterative, scenario-based approach was used to identify unique considerations in pediatric care and relevant human factors concepts. A draft of the recommendations were reviewed by invited experts in pediatric informatics, emergency medicine, neonatology, pediatrics, HFE, nursing, usability engineering, and software development and implementation. RECOMMENDATIONS Recommendations for EHR developers, small-group pediatric medical practices, and childrens hospitals were identified out of the original 54 recommendations, in terms of nine critical user interaction categories: patient identification, medications, alerts, growth chart, vaccinations, labs, newborn care, privacy, and radiology. CONCLUSION Pediatric patient care has unique dimensions, with great complexity and high stakes for adverse events. The recommendations are anticipated to increase the rate of EHR adoption by pediatric care providers and improve patient safety for pediatric patients. The described methodology might be useful for accelerating adoption and increasing safety in a variety of clinical areas where the adoption of EHRs is lagging or usability issues are believed to reduce potential patient safety, efficiency, and quality benefits.

Perspectives of knowledge management in urban health

Section I KM and Urban Health.- Chapter 1: Knowledge Management for the Urban Health Context.- Chapter 2: Healthcare Knowledge Management: Incorporating the Tools, Technologies, Strategies and Processes of KM to Effect Superior Healthcare Delivery.- Chapter 3: Knowledge Management in the Urban Health Context: Moving Towards Tacit-to-Tacit Knowledge Transfer.- Section II Incorporating KM Principles into Urban Health Contexts.- Chapter 4: A Childhood / Adolescent Knowledge Management System for Urban Area Health Programs in the District of Columbia.- Chapter 5: Urban Health in Developing Countries.- Chapter 6: A Pervasive Wireless Knowledge Management Solution to Address Urban Health Inequalities with Indigenous Australians.- Chapter 7: The Development of a Framework to Evaluate the Management of HIV/AIDS Programmes in Rural and Urban South Africa.- Chapter 8: The potential of Serious Games for Combating Health Inequalities.- Section III Measures and Metrics for KM and Urban Health.- Chapter 9: A Scaleable and Viable Strategy for Managing Organizing: Typology for Intervening into Complex Healthcare Environments for Enhancing Continual Development.- Chapter 10: Amplifying Resonance in Organizational Learning Process: Knowledge Sharing for Overcoming Cognitive Barriers and for Assuring Positive Action.- Chapter 11: Developing New Urban Health Metrics to Reduce the Know-Do Gap in Public Health.- Chapter 12: Recommendations on Evaluation and Development of Useful Metrics for Urban Health.- Chapter 13: Making Sense of Urban Health Knowledge

Improving Clinical Workflow in Ambulatory Care: Implemented Recommendations in an Innovation Prototype for the Veteran’s Health Administration

Introduction: Human factors workflow analyses in healthcare settings prior to technology implemented are recommended to improve workflow in ambulatory care settings. In this paper we describe how insights from a workflow analysis conducted by NIST were implemented in a software prototype developed for a Veteran’s Health Administration (VHA) VAi2 innovation project and associated lessons learned. Methods: We organize the original recommendations and associated stages and steps visualized in process maps from NIST and the VA’s lessons learned from implementing the recommendations in the VAi2 prototype according to four stages: 1) before the patient visit, 2) during the visit, 3) discharge, and 4) visit documentation. NIST recommendations to improve workflow in ambulatory care (outpatient) settings and process map representations were based on reflective statements collected during one-hour discussions with three physicians. The development of the VAi2 prototype was conducted initially independently from the NIST recommendations, but at a midpoint in the process development, all of the implementation elements were compared with the NIST recommendations and lessons learned were documented. Findings: Story-based displays and templates with default preliminary order sets were used to support scheduling, time-critical notifications, drafting medication orders, and supporting a diagnosis-based workflow. These templates enabled customization to the level of diagnostic uncertainty. Functionality was designed to support cooperative work across interdisciplinary team members, including shared documentation sessions with tracking of text modifications, medication lists, and patient education features. Displays were customized to the role and included access for consultants and site-defined educator teams. Discussion: Workflow, usability, and patient safety can be enhanced through clinician-centered design of electronic health records. The lessons learned from implementing NIST recommendations to improve workflow in ambulatory care using an EHR provide a first step in moving from a billing-centered perspective on how to maintain accurate, comprehensive, and up-to-date information about a group of patients to a clinician-centered perspective. These recommendations point the way towards a “patient visit management system,” which incorporates broader notions of supporting workload management, supporting flexible flow of patients and tasks, enabling accountable distributed work across members of the clinical team, and supporting dynamic tracking of steps in tasks that have longer time distributions.

A Community Health Initiative: Evaluation and Early Lessons Learned

Background: Community-based participatory research (CBPR) has been shown to enhance trust and engagement among community academic partners. However, the value of CBPR among hyper-researched, inner-city communities has not been evaluated adequately. The purpose of this study was to evaluate the impact of a CBPR based engagement process in an inner-city, hyper-researched, underserved community.Methods: A qualitative process evaluation was conducted using focus groups, key informant in-depth interviews, and a brief survey to evaluate the attitudes, perceptions, beliefs, impact of, and satisfaction with the CBPR engagement process used to plan and conduct a community asset mapping project.Results: Three focus groups, eight in-depth interviews, and survey responses from 31 individuals were obtained and analyzed. Findings include a sense of accomplishment and value with the engagement process, as well as a sense of tangible benefits of the process perceived by community members and academic research partners.Conclusions: CBPR may represent an effective approach to enhancing trust and community–academic collaboration even among cynical, resistant, hyper-researched, underserved communities.

Applying Human Factors Principles to Mitigate Usability Issues Related to Embedded Assumptions in Health Information Technology Design

Background There is growing recognition that design flaws in health information technology (HIT) lead to increased cognitive work, impact workflows, and produce other undesirable user experiences that contribute to usability issues and, in some cases, patient harm. These usability issues may in turn contribute to HIT utilization disparities and patient safety concerns, particularly among “non-typical” HIT users and their health care providers. Health care disparities are associated with poor health outcomes, premature death, and increased health care costs. HIT has the potential to reduce these disparate outcomes. In the computer science field, it has long been recognized that embedded cultural assumptions can reduce the usability, usefulness, and safety of HIT systems for populations whose characteristics differ from “stereotypical” users. Among these non-typical users, inappropriate embedded design assumptions may contribute to health care disparities. It is unclear how to address potentially inappropriate embedded HIT design assumptions once detected. Objective The objective of this paper is to explain HIT universal design principles derived from the human factors engineering literature that can help to overcome potential usability and/or patient safety issues that are associated with unrecognized, embedded assumptions about cultural groups when designing HIT systems. Methods Existing best practices, guidance, and standards in software usability and accessibility were subjected to a 5-step expert review process to identify and summarize those best practices, guidance, and standards that could help identify and/or address embedded design assumptions in HIT that could negatively impact patient safety, particularly for non-majority HIT user populations. An iterative consensus-based process was then used to derive evidence-based design principles from the data to address potentially inappropriate embedded cultural assumptions. Results Design principles that may help identify and address embedded HIT design assumptions are available in the existing literature. Conclusions Evidence-based HIT design principles derived from existing human factors and informatics literature can help HIT developers identify and address embedded cultural assumptions that may underlie HIT-associated usability and patient safety concerns as well as health care disparities.

The Patient of the Future: Participatory Medicine and Enabling Technologies

Several forces will progressively change the current US healthcare system. First, patient factors will likely exert the greatest impact. The rapidly growing US population, a growing percentage of seniors, increasing prevalence of chronic disease, increasing racial/ethnic diversity and persisting healthcare disparities will strain an already overloaded system. Second, healthcare system factors are also contributing to challenges. Shortages in the healthcare workforce, the rising costs, complexity and chronicity of care, the burdens of caregivers as primary health providers, the failure to address social determinants of health and the emergence of retail healthcare will exacerbate that strain. This chapter discusses implications of these forces in the context of health information systems evolving to meet these healthcare challenges. We conclude with a case study of a potential future patient-centered health information system and a discussion of patient-oriented features of effective health information systems.