Mustafa Ozkaynak

Revisiting sociotechnical systems in a case of unreported use of health information exchange system in three hospital emergency departments

BACKGROUND Health information exchange (HIE) allows clinicians to access patient level health care information. HIE can potentially improve patient care in emergency departments. METHODS We present a selected piece of evaluation of an HIE implementation in three Midwestern emergency departments. Data were collected through over 210 hours of direct observations and short interviews with 13 clinicians. RESULTS The results suggest that the usage rate of the HIE was low. Moreover, two ways of unreported use of the HIE system by clinicians was uncovered: (1) The HIE system was being used mostly for patients only with specific characteristics. (2) The information from the HIE system could be used to confront with the patients. DISCUSSION This study provides a case of how social system may shape a HIE technology. In order to fully benefit from HIE, understanding organizational and social context during the HIE design and implementation is needed. Such an understanding will also allow us to identify and detail required additional resources and organizational interventions that will complement HIE such as a case management strategy.

Characterizing patient care in hospital emergency departments

The purpose of this study is to characterize the early stage (i.e., until first prescriber order) of patient care in emergency departments (EDs) by focusing on the temporal sequence of activities by multiple roles. A hundred and eight patient care episodes in three EDs were observed and modeled as patient-oriented workflows. Capturing individual episodes allowed us to account for cooperative work in EDs. Data analysis revealed a high level of variability across patient care episodes. We also identified six patterns differentiated primarily by whether the prescriber is a physician or midlevel clinician. Secondary differentiators included whether the patient arrived in the ED as walk-in or via ambulance, and in which ED the patient care occurred. The high level of workflow variability reported in this study should be recognized in the design of ED work systems. Moreover, work interventions should not limit EDs’ capacity to handle sequential variability in patient care.

Clinical Workflow Analysis, Process Redesign, and Quality Improvement

Healthcare workflow is driven by individual, organizational, and societal factors. The resulting complexity and high variability make it challenging to examine workflow in healthcare delivery settings. In this chapter, the authors introduce relevant theories, frameworks, principles, tools, and techniques to guide both (a) workflow examination and (b) systematic organizational interventions for workflow redesign. These theories, frameworks, principles, tools, and techniques can be applied to diverse settings to improve the quality and safety of healthcare delivery.

Characterizing workflow for pediatric asthma patients in emergency departments using electronic health records

OBJECTIVE The purpose of this study was to describe a workflow analysis approach and apply it in emergency departments (EDs) using data extracted from the electronic health record (EHR) system. MATERIALS AND METHODS We used data that were obtained during 2013 from the ED of a childrens hospital and its four satellite EDs. Workflow-related data were extracted for all patient visits with either a primary or secondary diagnosis on discharge of asthma (ICD-9 code=493). For each patient visit, eight different a priori time-stamped events were identified. Data were also collected on mode of arrival, patient demographics, triage score (i.e. acuity level), and primary/secondary diagnosis. Comparison groups were by acuity levels 2 and 3 with 2 being more acute than 3, arrival mode (ambulance versus walk-in), and site. Data were analyzed using a visualization method and Markov Chains. RESULTS To demonstrate the viability and benefit of the approach, patient care workflows were visually and quantitatively compared. The analysis of the EHR data allowed for exploration of workflow patterns and variation across groups. Results suggest that workflow was different for different arrival modes, settings and acuity levels. DISCUSSION EHRs can be used to explore workflow with statistical and visual analytics techniques novel to the health care setting. The results generated by the proposed approach could be utilized to help institutions identify workflow issues, plan for varied workflows and ultimately improve efficiency in caring for diverse patient groups. CONCLUSION EHR data and novel analytic techniques in health care can expand our understanding of workflow in both large and small ED units.

Infinicare framework for integrated understanding of health-related activities in clinical and daily-living contexts

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.

An analysis of patient-provider secure messaging at two Veterans Health Administration medical centers: message content and resolution through secure messaging

Objective We sought to understand how patients and primary care teams use secure messaging (SM) to communicate with one another by analyzing secure message threads from 2 Department of Veterans Affairs facilities. Methods We coded 1000 threads of SM communication sampled from 40 primary care teams. Results Most threads (94.5%) were initiated by patients (90.4%) or caregivers (4.1%); only 5.5% were initiated by primary care team members proactively reaching out to patients. Medication renewals and refills (47.2%), scheduling requests (17.6%), medication issues (12.9%), and health issues (12.7%) were the most common patient-initiated requests, followed by referrals (7.0%), administrative issues (6.5%), test results (5.4%), test issues (5.2%), informing messages (4.9%), comments about the patient portal or SM (4.1%), appreciation (3.9%), self-reported data (2.8%), life issues (1.5%), and complaints (1.5%). Very few messages were clinically urgent (0.7%) or contained other potentially challenging content. Message threads were mostly short (2.7 messages), comprising an average of 1.35 discrete content types. A substantial proportion of issues (24.2%) did not show any evidence of being resolved through SM. Time to response and extent of resolution via SM varied by message content. Proactive SM use by teams varied, but was most often for test results (32.7%), medication-related issues (21.8%), medication renewals (16.4%), or scheduling issues (18.2%). Conclusions The majority of messages were transactional and initiated by patients or caregivers. Not all content categories were fully addressed over SM. Further education and training for both patients and clinical teams could improve the quality and efficiency of SM communication.

The Colorado Collaborative for Nursing Research: Nurses shaping nursing's future

Nurses in the present health care environment have been reduced too often to being providers of safe, competent care rather than quality care. In response, the Institute of Medicine has recommended that nurses become more involved in making changes to the health care system and use data more effectively. If nursing intends to follow these recommendations, the profession needs (a) fresh perspectives to assist in making health care system changes, (b) partnerships between nurse scientists and nurse clinicians to generate and implement data, and (c) capture of the proper value of nursing as distinct from other elements of health care delivery. The Colorado Collaborative for Nursing Research is an effort to meet the recommendations of the Institute of Medicine. The Colorado Collaborative for Nursing Research has a three-arm structure: a research forum where nurse academicians and nurse clinicians can launch collaborative projects; a research support services arm from which nurse collaborators can obtain help with modeling, statistics, writing, and funding; and a data extraction/data sharing mechanism to inform the decision making of nurse leaders.

Patient Work Methods: Current Methods of Engaging Patients in Systems Design in Clinical, Community and Extraterrestrial Settings

As Human Factors and Ergonomics (HF/E) practice in health care expands, there is growing recognition of the need to consider and design for patient work. Over the past several years HF/E practitioners and researchers have begun to formalize the theoretical foundations of a patient work approach. Methodologically, patient work approaches have required adaptations of existing HF/E and social science approaches as well as the development of new approaches. This panel will focus on current approaches of engaging patients in designing interventions in the multiple settings in which patient work is performed. Each panelist will introduce their work by discussing the health care challenge and how existing methods were adapted or new methods created to engage patients in the design of systems. The panelists will then interact with audience members to solicit current health care challenges and to brainstorm ways in which methods could be adapted or innovated to engage patients in addressing these challenges.