Factors Associated with Dissatisfaction in Medical Care Quality among Older Medicare Beneficiaries Suffering from Mental Illness.

Approximately 25% of US older adults live with a mental health disorder. The mental health needs of this population are chiefly met by primary care providers. Primary care practices may have inadequate strategies to provide satisfactory care to mentally ill older adults. This study used Centers for Medicare and Medicaid Services data to identify factors, including racial/ethnic differences, associated with dissatisfaction with medical care quality among older adults diagnosed with a mental health disorder. Our findings suggest factors that can be addressed to improve satisfaction with medical care quality and potentially promote adherence and follow-up for mentally ill older adults.

Advocating for HIT That Captures Nursing Process.

Nurses can influence choices about EHR systems and their design.

Informatics and Data Science for the Precision in Symptom Self-Management Center.

The goal of the Precision in Symptom Self-Management (PriSSM) Center is to advance the science of symptom self-management for Latinos through a social ecological lens that takes into account variability in individual, interpersonal, organizational, and environmental factors across the life course. Informatics and data science methods are foundational to PriSSM's research activities including its pilot studies and research resources. This work highlights three areas: Latino Data Repository, Information Visualization, and Center Evaluation.

Usability Evaluation of a Dashboard for Home Care Nurses.

The introduction of electronic health records has produced many challenges for clinicians. These include integrating technology into clinical workflow and fragmentation of relevant information across systems. Dashboards, which use visualized data to summarize key patient information, have the potential to address these issues. In this article, we outline a usability evaluation of a dashboard designed for home care nurses. An iterative design process was used, which consisted of (1) contextual inquiry (observation and interviews) with two home care nurses; (2) rapid feedback on paper prototypes of the dashboard (10 nurses); and (3) usability evaluation of the final dashboard prototype (20 nurses). Usability methods and assessments included observation of nurses interacting with the dashboard, the system usability scale, and the Questionnaire for User Interaction Satisfaction short form. The dashboard prototype was deemed to have high usability (mean system usability scale, 73.2 [SD, 18.8]) and was positively evaluated by nurse users. It is important to ensure that technology solutions such as the one proposed in this article are designed with clinical users in mind, to meet their information needs. The design elements of the dashboard outlined in this article could be translated to other electronic health records used in home care settings.

Factors Influencing Sustained Engagement with ECG Self-Monitoring: Perspectives from Patients and Health Care Providers.

BACKGROUND: Patient-generated health data (PGHD) collected digitally with mobile health (mHealth) technology has garnered recent excitement for its potential to improve precision management of chronic conditions such as atrial fibrillation (AF), a common cardiac arrhythmia. However, sustained engagement is a major barrier to collection of PGHD. Little is known about barriers to sustained engagement or strategies to intervene upon engagement through application design. OBJECTIVE: This article investigates individual patient differences in sustained engagement among individuals with a history of AF who are self-monitoring using mHealth technology. METHODS: This qualitative study involved patients, health care providers, and research coordinators previously involved in a randomized, controlled trial involving electrocardiogram (ECG) self-monitoring of AF. Patients were adults with a history of AF randomized to the intervention arm of this trial who self-monitored using ECG mHealth technology for 6 months. Semistructured interviews and focus groups were conducted separately with health care providers and research coordinators, engaged patients, and unengaged patients. A validated model of sustained engagement, an adapted unified theory of acceptance and use of technology (UTAUT), guided data collection, and analysis through directed content analysis. RESULTS: We interviewed 13 patients (7 engaged, 6 unengaged), 6 providers, and 2 research coordinators. In addition to finding differences between engaged and unengaged patients within each predictor in the adapted UTAUT model (perceived ease of use, perceived usefulness, facilitating conditions), four additional factors were identified as being related to sustained engagement in this population. These are: (1) internal motivation to manage health, (2) relationship with health care provider, (3) supportive environments, and (4) feedback and guidance. CONCLUSION: Although it required some modification, the adapted UTAUT model was useful in understanding of the parameters of sustained engagement. The findings of this study provide initial requirement specifications for the design of applications that engage patients in this unique population of adults with AF.

A multi-level usability evaluation of mobile health applications: A case study.

OBJECTIVE: To report a methodological approach for the development of a usable mHealth application (app). MATERIALS AND METHODS: This work was guided by a 3-level stratified view of health information technology (IT) usability evaluation framework. We first describe a number of methodologies for operationalizing each level of the framework. Following the description of each methodology, we present a case study which illustrates the use of our preferred methodologies for the development of a mHealth app. At level 1 (user-task), we applied a card sorting technique to guide the information architecture of a mobile HIV symptom self-management app, entitled mVIP. At level 2 (user-task-system), we conducted a usability evaluation of mVIP in a laboratory setting through end-user usability testing and heuristic evaluation with informatics experts. At level 3 (user-task-system-environment), usability of mVIP was evaluated in a real-world setting following the use of the app during a 3-month trial. RESULTS: The 3-level usability evaluation guided our work exploring in-depth interactions between the user, task, system, and environment. Integral to the findings from the 3-level usability evaluation, we iteratively refined the app's content, functionality, and interface to meet the needs of our intended end-users. DISCUSSION AND CONCLUSION: The stratified view of the health IT usability evaluation framework is a useful methodological approach for the design, development, and evaluation of mHealth apps. The methodological recommendations for using the theoretical framework can inform future usability studies of mHealth apps.

The Development of Heuristics for Evaluation of Dashboard Visualizations.

BACKGROUND: Heuristic evaluation is used in human-computer interaction studies to assess the usability of information systems. Nielsen's widely used heuristics, first developed in 1990, are appropriate for general usability but do not specifically address usability in systems that produce information visualizations. OBJECTIVE: This article develops a heuristic evaluation checklist that can be used to evaluate systems that produce information visualizations. Principles from Nielsen's heuristics were combined with heuristic principles developed by prior researchers specifically to evaluate information visualization. METHODS: We used nominal group technique to determine an appropriate final set. The combined existing usability principles and associated factors were distributed via email to a group of 12 informatics experts from a range of health care disciplines. Respondents were asked to rate each factor on its importance as an evaluation heuristic for visualization systems on a scale from 1 (definitely don't include) to 10 (definitely include). The distribution of scores for each item were calculated. A median score of ≥8 represented consensus for inclusion in the final checklist. RESULTS: Ten of 12 experts responded with rankings and written comments. The final checklist consists of 10 usability principles (7 general and 3 specific to information visualization) substantiated by 49 usability factors. Three nursing informatics experts then used the checklist to evaluate a vital sign dashboard developed for home care nurses, using a task list designed to explore the full functionality of the dashboard. The experts used the checklist without difficulty, and indicated that it covered all major usability problems encountered during task completion. CONCLUSION: The growing capacity to generate and electronically process health data suggests that data visualization will be increasingly important. A checklist of usability heuristics for evaluating information visualization systems can contribute to assuring high quality in electronic data systems developed for health care.

Relationships Among DNP and PhD Students After Implementing a Doctoral Student Organization.

BACKGROUND: Early career contact, between clinically focused DNP and research-focused PhD nursing students, may encourage desirable intradisciplinary synergies. AIM: The aim of the study was to assess relationships among DNP and PhD nursing students after initiating a doctoral student organization. METHOD: An online survey assessed student interaction pre- and post-doctoral student organization implementation. Analysis consisted of paired t-test, social network analysis, and content analysis methods. RESULTS: Response rates were 72 percent (n = 86) and 60 percent (n = 72) before and after implementation. Network density and centralization increased by 17 percent and 3 percent, respectively; intradisciplinary ties increased by 39 percent. The average student had approximately two new relationships; clique membership increased by 60 percent. Narrative responses corroborated network measurements. CONCLUSION: We documented additional integration and organized communication among students after this strategy to increase collaboration. Educators preparing nurses to work across research and practice may consider network analysis methods to evaluate their efforts.

Converging and diverging needs between patients and providers who are collecting and using patient-generated health data: an integrative review.

Objective: This integrative review identifies convergent and divergent areas of need for collecting and using patient-generated health data (PGHD) identified by patients and providers (i.e., physicians, nurses, advanced practice nurses, physician assistants, and dietitians). Methods: A systematic search of 9 scholarly databases targeted peer-reviewed studies published after 2010 that reported patients' and/or providers' needs for incorporating PGHD in clinical care. The studies were assessed for quality and bias with the Mixed-Methods Appraisal Tool. The results section of each article was coded to themes inductively developed to categorize patient and provider needs. Distinct claims were extracted and areas of convergence and divergence identified. Results: Eleven studies met inclusion criteria. All had moderate to low risk of bias. Three themes (clinical, logistic, and technological needs), and 13 subthemes emerged. Forty-eight claims were extracted. Four were divergent and twenty were convergent. The remainder was discussed by only patients or only providers. Conclusion: As momentum gains for integrating PGHD into clinical care, this analysis of primary source data is critical to understanding the requirements of the 2 groups directly involved in collection and use of PGHD.

The impact of home care nurses' numeracy and graph literacy on comprehension of visual display information: implications for dashboard design.

Objective: To explore home care nurses' numeracy and graph literacy and their relationship to comprehension of visualized data. Materials and Methods: A multifactorial experimental design using online survey software. Nurses were recruited from 2 Medicare-certified home health agencies. Numeracy and graph literacy were measured using validated scales. Nurses were randomized to 1 of 4 experimental conditions. Each condition displayed data for 1 of 4 quality indicators, in 1 of 4 different visualized formats (bar graph, line graph, spider graph, table). A mixed linear model measured the impact of numeracy, graph literacy, and display format on data understanding. Results: In all, 195 nurses took part in the study. They were slightly more numerate and graph literate than the general population. Overall, nurses understood information presented in bar graphs most easily (88% correct), followed by tables (81% correct), line graphs (77% correct), and spider graphs (41% correct). Individuals with low numeracy and low graph literacy had poorer comprehension of information displayed across all formats. High graph literacy appeared to enhance comprehension of data regardless of numeracy capabilities. Discussion and Conclusion: Clinical dashboards are increasingly used to provide information to clinicians in visualized format, under the assumption that visual display reduces cognitive workload. Results of this study suggest that nurses' comprehension of visualized information is influenced by their numeracy, graph literacy, and the display format of the data. Individual differences in numeracy and graph literacy skills need to be taken into account when designing dashboard technology.

Technology Solutions to Support Care Continuity in Home Care: A Focus Group Study.

BACKGROUND: Elevated hospital readmission rates from home care are an indicator of poor care quality, and rates are particularly high for patients with heart failure. Readmissions may be avoided by optimizing continuity of care. PURPOSE: To explore perceptions among home care clinicians of the barriers they face and the information they need to improve care continuity for patients with heart failure. METHODS: Focus groups were conducted with teams of home care clinicians at a large certified home healthcare agency in the Northeastern United states. RESULTS: In total, there were 61 participants across 6 focus groups. Three overarching themes emerged: continuity of care and communication on care transitions, maintaining continuity of care during a home care episode (with subthemes tracking signs and symptoms and patient teaching), and health information technology (HIT) characteristics to support communication and care continuity. CONCLUSIONS: Our study highlights areas of improvement for HIT solutions that could support care delivery for patients with heart failure in a home care setting. IMPLICATIONS: Home care agencies planning to introduce technology can use these findings to assess if and how potential systems can support nurses to provide continuity of care across healthcare organizations and home care visits.

The Public Health Workforce Taxonomy: Revisions and Recommendations for Implementation.

Public health workforce size and composition have been difficult to accurately determine because of the wide variety of methods used to define job title terms, occupational categories, and worker characteristics. In 2014, a preliminary consensus-based public health workforce taxonomy was published to standardize the manner in which workforce data are collected and analyzed by outlining uniform categories and terms. We summarize development of the taxonomy's 2017 iteration and provide guidelines for its implementation in public health workforce development efforts. To validate its utility, the 2014 taxonomy was pilot tested through quantitative and qualitative methods to determine whether further refinements were necessary. Pilot test findings were synthesized, themed by axis, and presented for review to an 11-member working group drawn from the community of experts in public health workforce development who refined the taxonomy content and structure through a consensus process. The 2017 public health workforce taxonomy consists of 287 specific classifications organized along 12 axes, intended for producing standardized descriptions of the public health workforce. The revised taxonomy provides enhanced clarity and inclusiveness for workforce characterization and will aid public health workforce researchers and workforce planning decision makers in gathering comparable, standardized data to accurately describe the public health workforce.

An Efficient Nurse Practitioner-Led Community-Based Service Model for Delivering Coordinated Care to Persons With Serious Mental Illness at Risk for Homelessness [Formula: see text].

BACKGROUND: Access to mental health care is a struggle for those with serious mental illness (SMI). About 25% of homeless suffer from SMI, compared with 4.2% of the general population. OBJECTIVE: From 2003 to 2012, St. Paul's Center (SPC) operated a unique model to provide quality care to the homeless and those at risk for homelessness, incarceration, and unnecessary hospitalization because of SMI. Data were available for analysis for the years 2008 to 2010. DESIGN: The SPC was developed, managed, and staffed by board-certified psychiatric/mental health nurse practitioners, offering comprehensive mental health services and coordinated interventions. RESULTS: All clients were housed and none incarcerated. From 2008 to 2010, only 3% of clients were hospitalized, compared with 7.5% of adults with SMI. Clinical, academic, and community partnerships increased value, but Medicaid reimbursement was not available. CONCLUSION: Mental health provisions in the recently passed 21st Century Cures Act support community mental health specialty treatment. The SPC provides a template for similar nurse practitioner-led models.

Mass-Fatality Incident Preparedness Among Faith-Based Organizations.

Introduction Members of faith-based organizations (FBOs) are in a unique position to provide support and services to their local communities during disasters. Because of their close community ties and well-established trust, they can play an especially critical role in helping communities heal in the aftermath of a mass-fatality incident (MFI). Faith-based organizations are considered an important disaster resource and partner under the National Response Plan (NRP) and National Response Framework; however, their level of preparedness and response capabilities with respect to MFIs has never been evaluated. The purpose of this study was threefold: (1) to develop appropriate measures of preparedness for this sector; (2) to assess MFI preparedness among United States FBOs; and (3) to identify key factors associated with MFI preparedness. Problem New metrics for MFI preparedness, comprised of three domains (organizational capabilities, operational capabilities, and resource sharing partnerships), were developed and tested in a national convenience sample of FBO members. METHODS: Data were collected using an online anonymous survey that was distributed through two major, national faith-based associations and social media during a 6-week period in 2014. Descriptive, bivariate, and correlational analyses were conducted. RESULTS: One hundred twenty-four respondents completed the online survey. More than one-half of the FBOs had responded to MFIs in the previous five years. Only 20% of respondents thought that roughly three-quarters of FBO clergy would be able to respond to MFIs, with or without hazardous contamination. A higher proportion (45%) thought that most FBO clergy would be willing to respond, but only 37% thought they would be willing if hazardous contamination was involved. Almost all respondents reported that their FBO was capable of providing emotional care and grief counseling in response to MFIs. Resource sharing partnerships were typically in place with other voluntary organizations (73%) and less likely with local death care sector organizations (27%) or Departments of Health (DOHs; 32%). CONCLUSIONS: The study suggests improvements are needed in terms of staff training in general, and specifically, drills with planning partners are needed. Greater cooperation and inclusion of FBOs in national planning and training will likely benefit overall MFI preparedness in the US. Zhi Q , Merrill JA , Gershon RR . Mass-fatality incident preparedness among faith-based organizations. Prehosp Disaster Med. 2017;32(6):596-603.

Are We Ready for Mass Fatality Incidents? Preparedness of the US Mass Fatality Infrastructure.

OBJECTIVE: To assess the preparedness of the US mass fatality infrastructure, we developed and tested metrics for 3 components of preparedness: organizational, operational, and resource sharing networks. METHODS: In 2014, data were collected from 5 response sectors: medical examiners and coroners, the death care industry, health departments, faith-based organizations, and offices of emergency management. Scores were calculated within and across sectors and a weighted score was developed for the infrastructure. RESULTS: A total of 879 respondents reported highly variable organizational capabilities: 15% had responded to a mass fatality incident (MFI); 42% reported staff trained for an MFI, but only 27% for an MFI involving hazardous contaminants. Respondents estimated that 75% of their staff would be willing and able to respond, but only 53% if contaminants were involved. Most perceived their organization as somewhat prepared, but 13% indicated "not at all." Operational capability scores ranged from 33% (death care industry) to 77% (offices of emergency management). Network capability analysis found that only 42% of possible reciprocal relationships between resource-sharing partners were present. The cross-sector composite score was 51%; that is, half the key capabilities for preparedness were in place. CONCLUSIONS: The sectors in the US mass fatality infrastructure report suboptimal capability to respond. National leadership is needed to ensure sector-specific and infrastructure-wide preparedness for a large-scale MFI.

Sometimes more is more: iterative participatory design of infographics for engagement of community members with varying levels of health literacy.

OBJECTIVE: To collaborate with community members to develop tailored infographics that support comprehension of health information, engage the viewer, and may have the potential to motivate health-promoting behaviors. METHODS: The authors conducted participatory design sessions with community members, who were purposively sampled and grouped by preferred language (English, Spanish), age group (18-30, 31-60, >60 years), and level of health literacy (adequate, marginal, inadequate). Research staff elicited perceived meaning of each infographic, preferences between infographics, suggestions for improvement, and whether or not the infographics would motivate health-promoting behavior. Analysis and infographic refinement were iterative and concurrent with data collection. RESULTS: Successful designs were information-rich, supported comparison, provided context, and/or employed familiar color and symbolic analogies. Infographics that employed repeated icons to represent multiple instances of a more general class of things (e.g., apple icons to represent fruit servings) were interpreted in a rigidly literal fashion and thus were unsuitable for this community. Preliminary findings suggest that infographics may motivate health-promoting behaviors. DISCUSSION: Infographics should be information-rich, contextualize the information for the viewer, and yield an accurate meaning even if interpreted literally. CONCLUSION: Carefully designed infographics can be useful tools to support comprehension and thus help patients engage with their own health data. Infographics may contribute to patients' ability to participate in the Learning Health System through participation in the development of a robust data utility, use of clinical communication tools for health self-management, and involvement in building knowledge through patient-reported outcomes.

Innovative use of the integrative review to evaluate evidence of technology transformation in healthcare.

Healthcare is in a period significant transformational activity through the accelerated adoption of healthcare technologies, new reimbursement systems that emphasize shared savings and care coordination, and the common place use of mobile technologies by patients, providers, and others. The complexity of healthcare creates barriers to transformational activity and has the potential to inhibit the desired paths toward change envisioned by policymakers. Methods for understanding how change is occurring within this complex environment are important to the evaluation of delivery system reform and the role of technology in healthcare transformation. This study examines the use on an integrative review methodology to evaluate the healthcare literature for evidence of technology transformation in healthcare. The methodology integrates the evaluation of a broad set of literature with an established evaluative framework to develop a more complete understanding of a particular topic. We applied this methodology and the framework of punctuated equilibrium (PEq) to the analysis of the healthcare literature from 2004 to 2012 for evidence of technology transformation, a time during which technology was at the forefront of healthcare policy. The analysis demonstrated that the established PEq framework applied to the literature showed considerable potential for evaluating the progress of policies that encourage healthcare transformation. Significant inhibitors to change were identified through the integrative review and categorized into ten themes that describe the resistant structure of healthcare delivery: variations in the environment; market complexity; regulations; flawed risks and rewards; change theories; barriers; ethical considerations; competition and sustainability; environmental elements, and internal elements. We hypothesize that the resistant nature of the healthcare system described by this study creates barriers to the direct consumer involvement and engagement necessary for transformational change. Future policies should be directed at removing these barriers by demanding and emphasizing open technologies and unrestricted access to data versus as currently prescribed by technology vendors, practitioners, and policies that perpetuate market equilibrium.

Impact of laws aimed at healthcare-associated infection reduction: a qualitative study.

BACKGROUND: Healthcare-associated infections (HAIs) are preventable. Globally, laws aimed at reducing HAIs have been implemented. In the USA, these laws are at the federal and state levels. It is not known whether the state interventions are more effective than the federal incentives alone. OBJECTIVE: The aims of this study were to explore the impact federal and state HAI laws have on state departments of health and hospital stakeholders in the USA and to explore similarities and differences in perceptions across states. METHODS: A qualitative study was conducted. In 2012, we conducted semistructured interviews with key stakeholders from states with and without state-level laws to gain multiple perspectives. Interviews were transcribed and open coding was conducted. Data were analysed using content analysis and collected until theoretical saturation was achieved. RESULTS: Ninety interviews were conducted with stakeholders from 12 states (6 states with laws and 6 states without laws). We found an increase in state-level collaboration. The publicly reported data helped hospitals benchmark and focus leaders on HAI prevention. There were concerns about the publicly reported data (eg, lack of validation and timeliness). Resource needs were also identified. No major differences were expressed by interviewees from states with and without laws. CONCLUSIONS: While we could not tease out the impact of specific interventions, increased collaboration between departments of health and their partners is occurring. Harmonisation of HAI definitions and reporting between state and federal laws would minimise reporting burden. Continued monitoring of the progress of HAI prevention is needed.

Public health workforce taxonomy.

Thoroughly characterizing and continuously monitoring the public health workforce is necessary for ensuring capacity to deliver public health services. A prerequisite for this is to develop a standardized methodology for classifying public health workers, permitting valid comparisons across agencies and over time, which does not exist for the public health workforce. An expert working group, all of whom are authors on this paper, was convened during 2012-2014 to develop a public health workforce taxonomy. The purpose of the taxonomy is to facilitate the systematic characterization of all public health workers while delineating a set of minimum data elements to be used in workforce surveys. The taxonomy will improve the comparability across surveys, assist with estimating duplicate counting of workers, provide a framework for describing the size and composition of the workforce, and address other challenges to workforce enumeration. The taxonomy consists of 12 axes, with each axis describing a key characteristic of public health workers. Within each axis are multiple categories, and sometimes subcategories, that further define that worker characteristic. The workforce taxonomy axes are occupation, workplace setting, employer, education, licensure, certification, job tasks, program area, public health specialization area, funding source, condition of employment, and demographics. The taxonomy is not intended to serve as a replacement for occupational classifications but rather is a tool for systematically categorizing worker characteristics. The taxonomy will continue to evolve as organizations implement it and recommend ways to improve this tool for more accurate workforce data collection.