amia2014 – Healthcare Business Process Management Blog by Chuck Webster, MD, BSA (Accountancy), MSIS (Intelligent Systems), MSIE (Industrial Engineering), #HIMSS18 Social Media Ambassador

AMIA2014 Workflow Paper (Monday) Engineering for reliability in at-home chronic disease management

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[CW: Great table! > Table 2. Summary of reliability system design strategies used by participants to enhance self-care reminders.]

3:30PM Sunday

“Prospective Memory as a Basis for Task Planning and Recall

Remembering to perform all the tasks expected for proper self-management requires effective recall of what has already happened and a continuous scan of what needs to happen in the near future. The process of remembering is frequently framed as either of two types: (1) retrospective memory that is concerned with the retrieval of past memories of people, events, and words, or (2) prospective memory that is concerned with remembering to perform a planned action or intention in the future11. The latter process includes short-term intentions—such as daily intake of a medication—as well as delayed actions—such as going to an annual checkup appointment—that could occur weeks or months in the future. Outlined in Figure 1, the process for realizing a delayed intention begins with encoding the future action, retaining the intention, and then retrieving the intention at the appropriate time to complete the action. This can occur through either an explicit reminder system or through spontaneous retrieval. Actions such as remembering to take medication at breakfast often rely on spontaneous retrieval of the intention that is triggered through environmental and physiological cues linked to daily routines. However, intermittent actions further out in time often involve a more explicit signaling cue—such as creating an alarm on a phone—to retrieve and execute the action at the right time12. In the case of an individual managing a chronic condition, the capacity to reliably shape and direct future behavior is critical to successfully managing the disease. The role of both explicit and implicit reminder systems within this memory process is the focus of this paper.
….
Designing for Human Error

Importantly for systems-thinking, our study highlights the variety of ways that failures can occur in remembering to perform self-care management activities. Therefore, the design of reminder systems to support self-management should account for errors by making it easier to detect, evaluate, and respond to failures when they do occur.”

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AMIA2014 Workflow Paper (Wednesday) Patient-Centered Appointment Scheduling Using Agent-Based Simulation

10:30 Wednesday

[see Figure 2 – Flowchart scheduling process according to appointment type and scheduling method]

“Enhanced access and continuity are key components of patient-centered care. Existing studies show that several interventions such as providing same day appointments, walk-in services, after-hours care, and group appointments, have been used to redesign the healthcare systems for improved access to primary care. However, an intervention focusing on a single component of care delivery (i.e. improving access to acute care) might have a negative impact other components of the system (i.e. reduced continuity of care for chronic patients). Therefore, primary care clinics should consider implementing multiple interventions tailored for their patient population needs. We collected rapid ethnography and observations to better understand clinic workflow and key constraints. We then developed an agent-based simulation model that includes all access modalities (appointments, walk-ins, and after-hours access), incorporate resources and key constraints and determine the best appointment scheduling method that improves access and continuity of care. This paper demonstrates the value of simulation models to test a variety of alternative strategies to improve access to care through scheduling”

AMIA2014 Workflow Paper (Wednesday) Trends in Publication of Nursing Informatics Research

8:30 Wednesday

“We analyzed 741 journal articles on nursing informatics published in 7 biomedical/nursing informatics journals and 6 nursing journals from 2005 to 2013 to begin to understand publication trends in nursing informatics research and identify gaps. We assigned a research theme to each article using AMIA 2014 theme categories and normalized the citation counts using time from publication. Overall, nursing informatics research covered a broad spectrum of research topics in biomedical informatics and publication topics seem to be well aligned with the high priority research agenda identified by the nursing informatics community. The research themes with highest volume of publication were Clinical Workflow and Human Factors, Consumer Informatics and Personal Health Records, and Clinical Informatics, for which an increasing trend in publication was noted. Articles on Informatics Education and Workforce Development; Data Mining, NLP, Information Extraction; and Clinical Informatics showed steady and high volume of citations.

….

The research theme most frequently appearing for the past 9 years was Clinical Workflow and Human Factors.

….

It is noteworthy that Clinical Workflow and Human Factor is among the most frequently published and cited themes in nursing informatics research. This is not surprising considering the large amount of time that nurses spend working with clinical information system, especially EMRs(23). This research trend may also imply that nurses can make significant contributions to mitigating various EMR usability issues. In July of 2013, the Office of National Coordinator (ONC) hosted a meeting with stakeholders to discuss usability issues in EMRs. Representatives from a healthcare informatics professional group, an EMR certification agency, and the American Medical Association were invited and had a chance to provide testimonials. Common criticism was that designs and workflows of many EMRs largely focused on meeting the Meaningful Use (MU) requirements rather than usability(24–26)”

AMIA2014 Workflow Paper (Wednesday) Characterization of a Handoff Documentation Tool Through Usage Log Data

10:30 Wednesday

“Handoffs are a critical component of coordinated patient care; however, poor handoffs have been associated with near misses and adverse events. To address this, national agencies have recommended standardizing handoffs, for example through the use of handoff documentation tools. Recent research suggests that handoff tools, typically designed for physicians, are often used by non-physician providers as information sources. In this study, we investigated patterns of edits of an electronic handoff tool in a large teaching hospital through examination of its usage log data. Qualitative interviews with clinicians were used to triangulate log data findings. The analysis showed that despite its primary focus on facilitating transitions of care, information in the handoff documentation tool was updated throughout the day. Interviews with residents confirmed that they purposefully updated information to make it available for other members of their patient care teams. This further reiterates the view of electronic handoff tools as facilitators of team communication and coordination. However, the study also showed considerable variability in the frequency of updates between different units and across different patients. Further research is required to understand what factors drive such diversity in the use of electronic handoff tool and whether this diversity can be used to make inferences about patients’ conditions.

….

Handoff Tab was frequently edited throughout the day. This suggests that handoff documentation tools may be a valuable source of up to date information. Furthermore, clusters analysis indicates that different update patterns exist based on units and patients.”

AMIA2014 Workflow Paper (Wednesday) Participatory Design and Development of a Patient-centered Toolkit to Engage Hospitalized Patients and Care Partners in their Plan of Care

[Excellent paper!]

10:30 Wednesday

“Patient engagement has been identified as a key strategy for improving patient outcomes. In this paper, we describe the development and pilot testing of a web-based patient centered toolkit (PCTK) prototype to improve access to health information and to engage hospitalized patients and caregivers in the plan of care. Individual and group interviews were used to identify plan of care functional and workflow requirements and user interface design enhancements. Qualitative methods within a participatory design approach supported the development of a PCTK prototype that will be implemented on intensive care and oncology units to engage patients and professional care team members developing their plan of care during an acute hospitalization.

….

The research questions are:

1) What are the workflow requirements needed to support patient involvement in developing the plan of care and direct communication with providers?

2) What are the content/user interface requirements needed to support patient involvement in developing the plan of care and direct communication with providers?

….

Our specific aim was to identify the workflow and user interface requirements needed to support patient involvement in developing the plan of care and communicating with providers related to that plan during an acute hospitalization. We used an iterative participatory design approach to develop the plan of care and provider communication features of the PCTK.”

AMIA2014 Workflow Poster (Tuesday) An Extensible Integration Framework for Clinical Decision Support Applications

5:00 Tuesday

“The lack of mechanism to easily integrate CDS (Clinical Decision Support) applications into clinical workflow has become the major obstacle for the adoption and utilization of CDS applications. We design and develop an extensible integration framework to effectively manage and targeted deliver CDS applications to appropriate scenarios.”

AMIA2014 Workflow Poster (Tuesday) A Time-and-motion Study of Clinical Trial Eligibility Screening in a Pediatric Emergency Department

5:00 Tuesday

[CW: see Table. Time and percentage over all time spent on workflow activities.]

Determining patient eligibility is a major barrier to clinical trial enrollment. We conducted a time-and-motion study on the clinical trial eligibility screening workflow in a pediatric emergency department (ED). We observed the workflow activities and the major findings are presented. Most (50%) of the time is spent screening patients and performing procedures; the time spent walking and waiting suggests that rearranging work locations could save time.

AMIA2014 Workflow Poster (Tuesday) Google Glass for clinical procedures reference. Perception of optimal UI (user interface) and functionalities

5:00 Tuesday

“Many respondents liked the overall concept, but a significant number of questions were raised concerning patient privacy and degree of device acceptance in the patient population. Also technical limitations like: device security, heating problems and low battery time were found to be potential barriers to widespread device implementation.”

AMIA2014 Workflow Poster (Tuesday) A Comprehensive Simulation Modeling Methodology to Reduce Health Care Process Redesign Risk

5:00 Tuesday

“Problem. Redesign of high-risk health care processes can lead to unanticipated consequences. Ash, et al.1-2 highlighted the significance of understanding clinical practice processes prior to implementation of CPOE systems. Others3-4 have emphasized the need for better methods to assess EMR impact on clinician teamwork, and clinical communication processes. The persistent implementation failure of health information technology (HIT) innovations has escalated the need for better methods to assess pre-implementation workflow, and ongoing HIT implementation impact on workflow processes.3-4 A comprehensive process redesign methodology is needed to examine the potential impact of process redesign interventions in advance of implementation.”

AMIA2014 Workflow Poster (Tuesday) Automating Extraction and Calculation of Daily Dose and Duration for Medications in EHRs

5:00 Tuesday

[CW: open source workflow]

“As part of the eMERGE (electronic Medical Records and Genomics) project, we are engaged in studies that require the extraction of medication data from EHRs (Electronic Health Records). In order to calculate daily dose and duration of medications, we found it necessary to supplement the existing NLP (Natural Language Processing) tool we are using with additional techniques. The result is an open-source workflow that can be readily re-targeted to multiple medications and is 90% accurate.

….

We created an executable workflow in KNIME (Konstanz Information Miner, knime.org) for calculating average daily dose and duration for medications, which extracts the numerical data needed for the calculations in 3 major steps: 1) combining the results of the MedEx NLP tool on prescription order signature line text with discrete medication data from our EHR where available, both of which are mostly non-numeric; 2) using pattern matching (RegEx), Java, and other data transformation tasks in KNIME, to convert dose and duration into numeric fields in standardized units; and 3) applying logical rules, for duration in particular, prioritizing fields to determine an accurate daily dose and duration.”