Textual inference for eligibility criteria resolution in clinical trials.

Clinical trials are essential for determining whether new interventions are effective. In order to determine the eligibility of patients to enroll into these trials, clinical trial coordinators often perform a manual review of clinical notes in the electronic health record of patients. This is a very time-consuming and exhausting task. Efforts in this process can be expedited if these coordinators are directed toward specific parts of the text that are relevant for eligibility determination. In this study, we describe the creation of a dataset that can be used to evaluate automated methods capable of identifying sentences in a note that are relevant for screening a patient's eligibility in clinical trials. Using this dataset, we also present results for four simple methods in natural language processing that can be used to automate this task. We found that this is a challenging task (maximum F-score=26.25), but it is a promising direction for further research.

Time motion studies in healthcare: what are we talking about?

Time motion studies were first described in the early 20th century in industrial engineering, referring to a quantitative data collection method where an external observer captured detailed data on the duration and movements required to accomplish a specific task, coupled with an analysis focused on improving efficiency. Since then, they have been broadly adopted by biomedical researchers and have become a focus of attention due to the current interest in clinical workflow related factors. However, attempts to aggregate results from these studies have been difficult, resulting from a significant variability in the implementation and reporting of methods. While efforts have been made to standardize the reporting of such data and findings, a lack of common understanding on what "time motion studies" are remains, which not only hinders reviews, but could also partially explain the methodological variability in the domain literature (duration of the observations, number of tasks, multitasking, training rigor and reliability assessments) caused by an attempt to cluster dissimilar sub-techniques. A crucial milestone towards the standardization and validation of time motion studies corresponds to a common understanding, accompanied by a proper recognition of the distinct techniques it encompasses. Towards this goal, we conducted a review of the literature aiming at identifying what is being referred to as "time motion studies". We provide a detailed description of the distinct methods used in articles referenced or classified as "time motion studies", and conclude that currently it is used not only to define the original technique, but also to describe a broad spectrum of studies whose only common factor is the capture and/or analysis of the duration of one or more events. To maintain alignment with the existing broad scope of the term, we propose a disambiguation approach by preserving the expanded conception, while recommending the use of a specific qualifier "continuous observation time motion studies" to refer to variations of the original method (the use of an external observer recording data continuously). In addition, we present a more granular naming for sub-techniques within continuous observation time motion studies, expecting to reduce the methodological variability within each sub-technique and facilitate future results aggregation.

[The discharge process]. / Proceso de alta hospitalaria, revisión de la literatura.

Discharge is one of the most important processes that hospitalized patients must endure. This process is complex, requires coordination among several professionals and transfers an overwhelming amount of information to patients. Often, it is limited to the writing of the discharge summary, with a primary emphasis on the drug list. Since the rise of hospitalism in 1996, a greater emphasis has been placed on understanding this process and in developing interventions to make it more effective and safe. In our country, little is known about how this process is taking place. Probably the absence of financial penalties for readmissions has influenced in the lack of study and development of this process. In the USA the knowledge of the discharge process is well advanced, and several strategies have been developed for reducing adverse events, medication errors, and 30-days readmissions. Other interventions have increased patient satisfaction and the degree of knowledge about their conditions. The aim of this paper is to do a comprehensive review of the literature, to provide healthcare teams with various tools that could improve both the discharge process as well as the discharge summary. The final objective is to optimize the safety and satisfaction of our patients and the hospital metrics of quality.

[Biomedical informatics]. / Informática biomédica.

Biomedical Informatics is a new discipline that arose from the need to incorporate information technologies to the generation, storage, distribution and analysis of information in the domain of biomedical sciences. This discipline comprises basic biomedical informatics, and public health informatics. The development of the discipline in Chile has been modest and most projects have originated from the interest of individual people or institutions, without a systematic and coordinated national development. Considering the unique features of health care system of our country, research in the area of biomedical informatics is becoming an imperative.

[Competences on hypoglycemia management among healthcare professionals in a clinical hospital]. / Diagnóstico y manejo de la hipoglicemia en adultos diabéticos hospitalizados: evaluación de competencias en un equipo profesional multidisciplinario de salud.

BACKGROUND: A tight glycemic control of hospitalized patients increases the risk of hypoglycemia, whose management is not always optimal. AIM: To assess the hypoglycemia management competences of a multidisciplinary team in a clinical hospital. MATERIAL AND METHODS: An anonymous questionnaire about hypoglycemia management was answered by 11 staff physicians, 42 residents and 28 nurses of the department of medicine and critical care unit ofa university hospital. RESULTS: Respondents had a mean of 60% of correct answers, without significant differences between groups. The capillary blood glucose level that defines hypoglycemia was known by most of the respondents, but the value that defines severe episodes was known only by 60%. The initial management and follow up was well known only for severe episodes. Less than 50%o knew the blood glucose value that required continuing with treatment. CONCLUSIONS: Although most professionals are able to recognize hypoglycemia, the knowledge about is management if insufficient.

Development of a Health Information Technology Tool for Behavior Change to Address Obesity and Prevent Chronic Disease Among Adolescents: Designing for Dissemination and Sustainment Using the ORBIT Model.

Health information technology (HIT) has not been broadly adopted for use in outpatient healthcare settings to effectively address obesity in youth, especially among disadvantaged populations that face greater barriers to good health. A well-designed HIT tool can deliver behavior change recommendations and provide community resources to address this gap, and the Obesity-Related Behavioral Intervention Trials (ORBIT) model can guide its development and refinement. This article reports the application of the ORBIT model to (1) describe the characteristics and design of a novel HIT tool (the PREVENT tool) using behavioral theory, (2) illustrate the use of stakeholder-centered "designing for dissemination and sustainability" principles, and (3) discuss the practical implications and directions for future research. Two types of stakeholder engagement (customer discovery and user testing) were conducted with end users (outpatient healthcare teams). Customer discovery interviews (n = 20) informed PREVENT tool components and intervention targets by identifying (1) what healthcare teams (e.g., physicians, dietitians) identified as their most important "jobs to be done" in helping adolescents who are overweight/obese adopt healthy behaviors, (2) their most critical "pains" and "gains" related to overweight/obesity treatment, and (3) how they define success compared to competing alternatives. Interviews revealed the need for a tool to help healthcare teams efficiently deliver tailored, evidence-based behavior change recommendations, motivate patients, and follow-up with patients within the constraints of clinic schedules and workflows. The PREVENT tool was developed to meet these needs. It facilitates prevention discussions, delivers tailored, evidence-based recommendations for physical activity and food intake, includes an interactive map of community resources to support behavior change, and automates patient follow-up. Based on Self-Determination Theory, the PREVENT tool engages the patient to encourage competence and autonomy to motivate behavior change. The use of this intentional, user-centered design process should increase the likelihood of the intended outcomes (e.g., behavior change, weight stabilization/loss) and ultimately increase uptake, implementation success, and long-term results. After initial tool development, user-testing interviews (n = 13) were conducted using a think-aloud protocol that provided insight into users' (i.e., healthcare teams) cognitive processes, attitudes, and challenges when using the tool. Overall, the PREVENT tool was perceived to be useful, well-organized, and visually appealing.

Cardiovascular Assessment Tool for Breast Cancer Survivors and Oncology Providers: Usability Study.

BACKGROUND: Cardiovascular health is of increasing concern to breast cancer survivors and their health care providers, as many survivors are more likely to die from cardiovascular disease than cancer. Implementing clinical decision support tools to address cardiovascular risk factor awareness in the oncology setting may enhance survivors' attainment or maintenance of cardiovascular health. OBJECTIVE: We sought to evaluate survivors' awareness of cardiovascular risk factors and examine the usability of a novel electronic health record enabled cardiovascular health tool from the perspective of both breast cancer survivors and oncology providers. METHODS: Breast cancer survivors (n=49) recruited from a survivorship clinic interacted with the cardiovascular health tool and completed pre and posttool assessments about cardiovascular health knowledge and perceptions of the tool. Oncologists, physician assistants, and nurse practitioners (n=20) who provide care to survivors also viewed the cardiovascular health tool and completed assessments of perceived usability and acceptability. RESULTS: Enrolled breast cancer survivors (84% White race, 4% Hispanic ethnicity) had been diagnosed 10.8 years ago (SD 6.0) with American Joint Committee on Cancer stage 0, I, or II (45/49, 92%). Prior to viewing the tool, 65% of survivors (32/49) reported not knowing their level for one or more cardiovascular health factors (range 0-4). On average, only 45% (range 0%-86%) of survivors' known cardiovascular health factors were at an ideal level. More than 50% of survivors had ideal smoking status (45/48, 94%) or blood glucose level (29/45, 64%); meanwhile, less than 50% had ideal blood pressure (12/49, 24%), body mass index (12/49, 24%), cholesterol level (17/35, 49%), diet (7/49, 14%), and physical activity (10/49. 20%). More than 90% of survivors thought the tool was easy to understand (46/47, 98%), improved their understanding (43/47, 91%), and was helpful (45/47, 96%); overall, 94% (44/47 survivors) liked the tool. A majority of survivors (44/47, 94%) thought oncologists should discuss cardiovascular health during survivorship care. Most (12/20, 60%) oncology providers (female: 12/20, 60%; physicians: 14/20, 70%) had been practicing for more than 5 years. Most providers agreed the tool provided useful information (18/20, 90%), would help their effectiveness (18/20, 90%), was easy to use (20/20, 100%), and presented information in a useful format (19/20, 95%); and 85% of providers (17/20) reported they would use the tool most or all of the time when providing survivorship care. CONCLUSIONS: These usability data demonstrate acceptability of a cardiovascular health clinical decision support tool in oncology practices. Oncology providers and breast cancer survivors would likely value the integration of such apps in survivorship care. By increasing awareness and communication regarding cardiovascular health, electronic health record-enabled tools may improve survivorship care delivery for breast cancer and ultimately patient outcomes.

Foundations for Studying Clinical Workflow: Development of a Composite Inter-Observer Reliability Assessment for Workflow Time Studies.

The ability to understand and measure the complexity of clinical workflow provides hospital managers and researchers with the necessary knowledge to assess some of the most critical issues in healthcare. Given the protagonist role of workflow time studies on influencing decision makers, major efforts are being conducted to address existing methodological inconsistencies of the technique. Among major concerns, the lack of a standardized methodology to ensure the reliability of human observers stands as a priority. In this paper, we highlight the limitations of the current Inter-Observer Reliability Assessments, and propose a novel composite score to systematically conduct them. The composite score is composed of a) the overall agreement based on Kappa that evaluates the naming agreement on virtually created one-seconds tasks, providing a global assessment of the agreement over time, b) a naming agreement based on Kappa, requiring an observation pairing approach based on time-overlap, c) a duration agreement based on the concordance correlation coefficient, that provides means to evaluate the correlation concerning tasks duration, d) a timing agreement, based on descriptive statistics of the gaps between timestamps of same-task classes, and e) a sequence agreement based on the Needleman-Wunsch sequence alignment algorithm. We hereby provide a first step towards standardized reliability reporting in workflow time studies. This new composite IORA protocol is intended to empower workflow researchers with a standardized and comprehensive method for validating observers' reliability and, in turn, the validity of their data and results.

Nurses' Stress Associated with Nursing Activities and Electronic Health Records: Data Triangulation from Continuous Stress Monitoring, Perceived Workload, and a Time Motion Study.

As health IT has become overloaded with patient information, provider burnout and stress has accelerated. Studies have shown that EHR usage leads to heightened cognitive workload for nurses, and increases in cognitive workload can result in stronger feelings of exhaustion and burnout. We conducted a time motion study in an oncology division to examine the relationships between nurses' perceived workload, stress measured by blood pulse wave (BPw), and their time spent on nursing activities, and to identify stress associated with EHR use. We had a total of 33 observations from 7 nurses. We found that EHR-related stress is associated with nurses' perceived physical demand and frustration. We also found that nurses' perceived workload is a strong predictor of nurses' stress as well as how they spent time with their patients. They also experienced higher perceived mental demand, physical demand, and temporal demand when they were assigned to more patients, regardless of patient acuity. Our study presents a unique data triangulation approach from continuous stress monitoring, perceived workload, and a time motion study.

Nurses' Time Allocation and Multitasking of Nursing Activities: A Time Motion Study.

Nurses have been required to provide more patient-centered, efficient, and cost effective care. In order to do so, they need to work at the top of their license. We conducted a time motion study to document nursing activities on communication, hands-on tasks, and locations (where activities occurred), and compared differences between different time blocks (7am-11am, 11am-3pm, and 3pm-7pm). We found that nurses spent most of their time communicating with patients and in patient rooms. Nurses also spent most of their time charting and reviewing information in EHR, mostly at the nursing station. Nurses' work was not distributed equally across a 12-hour shift. We found that greater frequency and duration in hands-on tasks occurred between 7am-11am. In addition, nurses spent approximately 10% of their time on delegable and non-nursing activities, which could be used more effectively for patient care. The study results provide evidence to assist nursing leaders to develop strategies for transforming nursing practice through re-examination of nursing work and activities, and to promote nurses working at top of license for high quality care and best outcomes. Our research also presents a novel and quantifiable method to capture data on multidimensional levels of nursing activities.

Electronic health record-based assessment of cardiovascular health: The stroke prevention in healthcare delivery environments (SPHERE) study.

< 3% of Americans have ideal cardiovascular health (CVH). The primary care encounter provides a setting in which to conduct patient-provider discussions of CVH. We implemented a CVH risk assessment, visualization, and decision-making tool that automatically populates with electronic health record (EHR) data during the encounter in order to encourage patient-centered CVH discussions among at-risk, yet under-treated, populations. We quantified five of the seven CVH behaviors and factors that were available in The Ohio State University Wexner Medical Center's EHR at baseline (May-July 2013) and compared values to those ascertained at one-year (May-July 2014) among intervention (n = 109) and control (n = 42) patients. The CVH of women in the intervention clinic improved relative to the metrics of body mass index (16% to 21% ideal) and diabetes (62% to 68% ideal), but not for smoking, total cholesterol, or blood pressure. Meanwhile, the CVH of women in the control clinic either held constant or worsened slightly as measured using those same metrics. Providers need easy-to-use tools at the point-of-care to help patients improve CVH. We demonstrated that the EHR could deliver such a tool using an existing American Heart Association framework, and we noted small improvements in CVH in our patient population. Future work is needed to assess how to best harness the potential of such tools in order to have the greatest impact on the CVH of a larger patient population.

Understanding and Visualizing Multitasking and Task Switching Activities: A Time Motion Study to Capture Nursing Workflow.

A fundamental understanding of multitasking within nursing workflow is important in today's dynamic and complex healthcare environment. We conducted a time motion study to understand nursing workflow, specifically multitasking and task switching activities. We used TimeCaT, a comprehensive electronic time capture tool, to capture observational data. We established inter-observer reliability prior to data collection. We completed 56 hours of observation of 10 registered nurses. We found, on average, nurses had 124 communications and 208 hands-on tasks per 4-hour block of time. They multitasked (having communication and hands-on tasks simultaneously) 131 times, representing 39.48% of all times; the total multitasking duration ranges from 14.6 minutes to 109 minutes, 44.98 minutes (18.63%) on average. We also reviewed workflow visualization to uncover the multitasking events. Our study design and methods provide a practical and reliable approach to conducting and analyzing time motion studies from both quantitative and qualitative perspectives.

Usability and Workflow Evaluation of "RhEumAtic Disease activitY" (READY). A Mobile Application for Rheumatology Patients and Providers.

BACKGROUND: RhEumAtic Disease activitY (READY) is a mobile health (mHealth) application that aims to create a shared platform integrating data from both patients and physicians, with a particular emphasis on arthritis disease activity. METHODS: We made READY available on an iPad and pilot implemented it at a rheumatology outpatient clinic. We conducted 1) a usability evaluation study to explore patients' and physicians' interactions with READY, and 2) a time motion study (TMS) to observe the clinical workflow before and after the implementation. RESULTS: A total of 33 patients and 15 physicians participated in the usability evaluation. We found usability problems in navigation, data entry, pain assessment, documentation, and instructions along with error messages. Despite these issues, 25 (75,76%) patients reported they liked READY. Physicians provided mixed feedback because they were concerned about the impact of READY on clinical workflow. Six physicians participated in the TMS. We observed 47 patient visits (44.72 hours) in the pre-implementation phase, and 42 patient visits (37.82 hours) in the post-implementation phase. We found that patients spent more time on READY than paper (4.39mins vs. 2.26mins), but overall, READY did not delay the workflow (pre = 52.08 mins vs. post = 45.46 mins). This time difference may be compensated with READY eliminating a workflow step for the staff. CONCLUSION: Patients preferred READY to paper documents. Many found it easier to input information because of the larger font size and the ease of 'tapping' rather than writing-out or circling answers. Even though patients spent more time on READY than using paper documents, the longer usage of READY was mainly due to when troubleshooting was needed. Most patients did not have problems after receiving initial support from the staff. This study not only enabled improvements to the software but also serves as good reference for other researchers or institutional decision makers who are interested in implementing such a technology.

A Novel Approach to Create a Machine Readable Concept Model for Validating SNOMED CT Concept Post-coordination.

Post-coordination provides the means to achieve an appropriate content coverage, which is critical in successfully adopting clinical reference terminologies, and thus represent clinical information consistently. However, one of the major problems of post-coordination corresponds with ensuring only clinically sensible concepts can be constructed. In this poster, we present the development of a novel approach to generate a MRCM computationally, in order to facilitate the adherence to the existing guidelines and improve the quality of post-coordination in SNOMED CT.

Emergency Department Information System Education and Training for Clinicians: Lessons Learned.

Of all the potential barriers to a successful Electronic Health Record (EHR) adoption, the importance of training is often underestimated, potentially jeopardizing the implementation. Following best practices recommendations, we designed and implemented a comprehensive EHR training framework. The aim of this poster is to describe our experience with such a framework in the implementation of our home-grown Emergency Department Information System (EDIS), report lessons learned and provide recommendations for other institutions facing EHR adoptions in Chile and Latin America.

A Novel Multiple Choice Question Generation Strategy: Alternative Uses for Controlled Vocabulary Thesauri in Biomedical-Sciences Education.

Multiple choice questions play an important role in training and evaluating biomedical science students. However, the resource intensive nature of question generation limits their open availability, reducing their contribution to evaluation purposes mainly. Although applied-knowledge questions require a complex formulation process, the creation of concrete-knowledge questions (i.e., definitions, associations) could be assisted by the use of informatics methods. We envisioned a novel and simple algorithm that exploits validated knowledge repositories and generates concrete-knowledge questions by leveraging concepts' relationships. In this manuscript we present the development and validation of a prototype which successfully produced meaningful concrete-knowledge questions, opening new applications for existing knowledge repositories, potentially benefiting students of all biomedical sciences disciplines.

EHR-based Visualization Tool: Adoption Rates, Satisfaction, and Patient Outcomes.

BACKGROUND: Electronic health records (EHRs) have the potential to enhance patient-provider communication and improve patient outcomes. However, in order to impact patient care, clinical decision support (CDS) and communication tools targeting such needs must be integrated into clinical workflow and be flexible with regard to the changing health care landscape. DESIGN: The Stroke Prevention in Healthcare Delivery Environments (SPHERE) team developed and implemented the SPHERE tool, an EHR-based CDS visualization, to enhance patient-provider communication around cardiovascular health (CVH) within an outpatient primary care setting of a large academic medical center. IMPLEMENTATION: We describe our successful CDS alert implementation strategy and report adoption rates. We also present results of a provider satisfaction survey showing that the SPHERE tool delivers appropriate content in a timely manner. Patient outcomes following implementation of the tool indicate one-year improvements in some CVH metrics, such as body mass index and diabetes. DISCUSSION: Clinical decision-making and practices change rapidly and in parallel to simultaneous changes in the health care landscape and EHR usage. Based on these observations and our preliminary results, we have found that an integrated, extensible, and workflow-aware CDS tool is critical to enhancing patient-provider communications and influencing patient outcomes.

Assessment of Life's Simple 7 in the primary care setting: the Stroke Prevention in Healthcare Delivery EnviRonmEnts (SPHERE) study.

BACKGROUND: Adverse health behaviors and factors predict increased coronary heart disease and stroke risk, and effective use of health information technology (HIT) to automate assessment of and intervention on these factors is needed. A comprehensive, automated cardiovascular health (CVH) assessment deployed in the primary care setting offers the potential to enhance prevention, facilitate patient-provider communication, and ultimately reduce cardiovascular (CV) disease risk. We describe the methods for a study to develop and test an automated CVH application for stroke prevention in older women. METHODS AND RESULTS: The eligible study population for the Stroke Prevention in Healthcare Delivery EnviRonmEnts (SPHERE) study is approximately 1600 female patients aged 65 years and older and their primary care providers at The Ohio State University Wexner Medical Center. We will use an intervention design that will allow for a run-in period, comparison group data collection, a provider education period, and implementation of a best practice alert to prompt provider-patient interactions regarding CVH. Our primary outcome is a CVH score, comprising Life's Simple 7: smoking status, body mass index, blood pressure, cholesterol, fasting glucose, physical activity, and diet. The SPHERE application will generate visualizations of the CVH score within the electronic health record (EHR) during the patient-provider encounter. A key outcome of the study will be change in mean CVH score pre- and post-intervention. CONCLUSIONS: The SPHERE application leverages the EHR and may improve health outcomes through HIT designed to empower clinicians to discuss CVH with their patients and enhance primary prevention efforts.

Inter-observer reliability assessments in time motion studies: the foundation for meaningful clinical workflow analysis.

Understanding clinical workflow is critical for researchers and healthcare decision makers. Current workflow studies tend to oversimplify and underrepresent the complexity of clinical workflow. Continuous observation time motion studies (TMS) could enhance clinical workflow studies by providing rich quantitative data required for in-depth workflow analyses. However, methodological inconsistencies have been reported in continuous observation TMS, potentially reducing the validity of TMS' data and limiting their contribution to the general state of knowledge. We believe that a cornerstone in standardizing TMS is to ensure the reliability of the human observers. In this manuscript we review the approaches for inter-observer reliability assessment (IORA) in a representative sample of TMS focusing on clinical workflow. We found that IORA is an uncommon practice, inconsistently reported, and often uses methods that provide partial and overestimated measures of agreement. Since a comprehensive approach to IORA is yet to be proposed and validated, we provide initial recommendations for IORA reporting in continuous observation TMS.