Guidance for publishing qualitative research in informatics.

Qualitative research, the analysis of nonquantitative and nonquantifiable data through methods such as interviews and observation, is integral to the field of biomedical and health informatics. To demonstrate the integrity and quality of their qualitative research, authors should report important elements of their work. This perspective article offers guidance about reporting components of the research, including theory, the research question, sampling, data collection methods, data analysis, results, and discussion. Addressing these points in the paper assists peer reviewers and readers in assessing the rigor of the work and its contribution to the literature. Clearer and more detailed reporting will ensure that qualitative research will continue to be published in informatics, helping researchers disseminate their understanding of people, organizations, context, and sociotechnical relationships as they relate to biomedical and health data.

An Analysis of Electronic Health Record Work to Manage Asynchronous Clinical Messages among Breast Cancer Care Teams.

OBJECTIVE: Asynchronous messaging is an integral aspect of communication in clinical settings, but imposes additional work and potentially leads to inefficiency. The goal of this study was to describe the time spent using the electronic health record (EHR) to manage asynchronous communication to support breast cancer care coordination. METHODS: We analyzed 3 years of audit logs and secure messaging logs from the EHR for care team members involved in breast cancer care at Vanderbilt University Medical Center. To evaluate trends in EHR use, we combined log data into sequences of events that occurred within 15 minutes of any other event by the same employee about the same patient. RESULTS: Our cohort of 9,761 patients were the subject of 430,857 message threads by 7,194 employees over a 3-year period. Breast cancer care team members performed messaging actions in 37.5% of all EHR sessions, averaging 29.8 (standard deviation [SD] = 23.5) messaging sessions per day. Messaging sessions lasted an average of 1.1 (95% confidence interval: 0.99-1.24) minutes longer than nonmessaging sessions. On days when the cancer providers did not otherwise have clinical responsibilities, they still performed messaging actions in an average of 15 (SD = 11.9) sessions per day. CONCLUSION: At our institution, clinical messaging occurred in 35% of all EHR sessions. Clinical messaging, sometimes viewed as a supporting task of clinical work, is important to delivering and coordinating care across roles. Measuring the electronic work of asynchronous communication among care team members affords the opportunity to systematically identify opportunities to improve employee workload.

Classification and analysis of asynchronous communication content between care team members involved in breast cancer treatment.

OBJECTIVE: A growing research literature has highlighted the work of managing and triaging clinical messages as a major contributor to professional exhaustion and burnout. The goal of this study was to discover and quantify the distribution of message content sent among care team members treating patients with breast cancer. MATERIALS AND METHODS: We analyzed nearly two years of communication data from the electronic health record (EHR) between care team members at Vanderbilt University Medical Center. We applied natural language processing to perform sentence-level annotation into one of five information types: clinical, medical logistics, nonmedical logistics, social, and other. We combined sentence-level annotations for each respective message. We evaluated message content by team member role and clinic activity. RESULTS: Our dataset included 81 857 messages containing 613 877 sentences. Across all roles, 63.4% and 21.8% of messages contained logistical information and clinical information, respectively. Individuals in administrative or clinical staff roles sent 81% of all messages containing logistical information. There were 33.2% of messages sent by physicians containing clinical information-the most of any role. DISCUSSION AND CONCLUSION: Our results demonstrate that EHR-based asynchronous communication is integral to coordinate care for patients with breast cancer. By understanding the content of messages sent by care team members, we can devise informatics initiatives to improve physicians' clerical burden and reduce unnecessary interruptions.

Enabling adoption and use of new health information technology during implementation: Roles and strategies for internal and external support personnel.

OBJECTIVE: Successful technological implementations frequently involve individuals who serve as mediators between end users, management, and technology developers. The goal for this project was to evaluate the structure and activities of such mediators in a large-scale electronic health record implementation. MATERIALS AND METHODS: Field notes from observations taken during implementation beginning in November 2017 were analyzed qualitatively using a thematic analysis framework to examine the relationship between specific types of mediators and the type and level of support to end users. RESULTS: We found that support personnel possessing both contextual knowledge of the institution's workflow and training in the new technology were the most successful in mediation of adoption and use. Those that lacked context of either technology or institutional workflow often displayed barriers in communication, trust, and active problem solving. CONCLUSIONS: These findings suggest that institutional investment in technology training and explicit programs to foster skills in mediation, including roles for professionals with career development opportunities, prior to implementation can be beneficial in easing the pain of system transition.

Combatting human trafficking in the United States: how can medical informatics help?

OBJECTIVE: Human trafficking is a global problem taking many forms, including sex and labor exploitation. Trafficking victims can be any age, although most trafficking begins when victims are adolescents. Many trafficking victims have contact with health-care providers across various health-care contexts, both for emergency and routine care. MATERIALS AND METHODS: We propose 4 specific areas where medical informatics can assist with combatting trafficking: screening, clinical decision support, community-facing tools, and analytics that are both descriptive and predictive. Efforts to implement health information technology interventions focused on trafficking must be carefully integrated into existing clinical work and connected to community resources to move beyond identification to provide assistance and to support trauma-informed care. RESULTS: We lay forth a research and implementation agenda to integrate human trafficking identification and intervention into routine clinical practice, supported by health information technology. CONCLUSIONS: A sociotechnical systems approach is recommended to ensure interventions address the complex issues involved in assisting victims of human trafficking.

Organizational diagnostics: a systematic approach to identifying technology and workflow issues in clinical settings.

OBJECTIVES: Healthcare organizations need to rapidly adapt to new technology, policy changes, evolving payment strategies, and other environmental changes. We report on the development and application of a structured methodology to support technology and process improvement in healthcare organizations, Systematic Iterative Organizational Diagnostics (SIOD). SIOD was designed to evaluate clinical work practices, diagnose technology and workflow issues, and recommend potential solutions. MATERIALS AND METHODS: SIOD consists of five stages: (1) Background Scan, (2) Engagement Building, (3) Data Acquisition, (4) Data Analysis, and (5) Reporting and Debriefing. Our team applied the SIOD approach in two ambulatory clinics and an integrated ambulatory care center and used SIOD components during an evaluation of a large-scale health information technology transition. RESULTS: During the initial SIOD application in two ambulatory clinics, five major analysis themes were identified, grounded in the data: putting patients first, reducing the chaos, matching space to function, technology making work harder, and staffing is more than numbers. Additional themes were identified based on SIOD application to a multidisciplinary clinical center. The team also developed contextually grounded recommendations to address issues identified through applying SIOD. DISCUSSION: The SIOD methodology fills a problem identification gap in existing process improvement systems through an emphasis on issue discovery, holistic clinic functionality, and inclusion of diverse perspectives. SIOD can diagnose issues where approaches as Lean, Six Sigma, and other organizational interventions can be applied. CONCLUSION: The complex structure of work and technology in healthcare requires specialized diagnostic strategies to identify and resolve issues, and SIOD fills this need.

Everyday objects and spaces: How they afford resilience in diabetes routines.

Thirty million Americans currently have diabetes, and a substantial portion do not reach the goals of clinical treatment. This is in part due to the complex barriers to effective self-care faced by people with diabetes. This study uses a patient work perspective, focusing on the everyday, lived experience of managing diabetes. Our primary research goal was to explore how the work of self-care is embedded in the other routines of everyday living. We found that everyday objects and spaces were instrumental in the incorporation of diabetes work into daily routines. Objects anchored diabetes tasks by linking illness-specific artifacts to space and time (e.g. a morning routine), and by enabling the performance on diabetes tasks while on the move in either planned or unplanned ways.

Characterizing communication patterns among members of the clinical care team to deliver breast cancer treatment.

OBJECTIVE: Research to date focused on quantifying team collaboration has relied on identifying shared patients but does not incorporate the major role of communication patterns. The goal of this study was to describe the patterns and volume of communication among care team members involved in treating breast cancer patients. MATERIALS AND METHODS: We analyzed 4 years of communications data from the electronic health record between care team members at Vanderbilt University Medical Center (VUMC). Our cohort of patients diagnosed with breast cancer was identified using the VUMC tumor registry. We classified each care team member participating in electronic messaging by their institutional role and classified physicians by specialty. To identify collaborative patterns, we modeled the data as a social network. RESULTS: Our cohort of 1181 patients was the subject of 322 424 messages sent in 104 210 unique communication threads by 5620 employees. On average, each patient was the subject of 88.2 message threads involving 106.4 employees. Each employee, on average, sent 72.9 messages and was connected to 24.6 collaborators. Nurses and physicians were involved in 98% and 44% of all message threads, respectively. DISCUSSION AND CONCLUSION: Our results suggest that many providers in our study may experience a high volume of messaging work. By using data routinely generated through interaction with the electronic health record, we can begin to evaluate how to iteratively implement and assess initiatives to improve the efficiency of care coordination and reduce unnecessary messaging work across all care team roles.

Improving the Effectiveness of Health Information Technology: The Case for Situational Analytics.

Health information technology has contributed to improvements in quality and safety in clinical settings. However, the implementation of new technologies in health care has also been associated with the introduction of new sociotechnical hazards, produced through a range of complex interactions that vary with social, physical, temporal, and technological context. Other industries have been confronted with this problem and have developed advanced analytics to examine context-specific activities of workers and related outcomes. The skills and data exist in health care to develop similar insights through situational analytics, defined as the application of analytic methods to characterize human activity in situations and identify patterns in activity and outcomes that are influenced by contextual factors. This article describes the approach of situational analytics and potentially useful data sources, including trace data from electronic health record activity, reports from users, qualitative field data, and locational data. Key implementation requirements are discussed, including the need for collaboration among qualitative researchers and data scientists, organizational and federal level infrastructure requirements, and the need to implement a parallel research program in ethics to understand how the data are being used by organizations and policy makers.

Physician Perspectives on Training for an EHR Implementation.

In 2017, a US academic medical center switched to a commercial EHR system using the "specialist training the specialist" model, which combines peer-to-peer training, classroom based training, and web-based training. We conducted semi-structured interviews with physicians at multiple training levels to investigate the impact of this EHR switch and to explore the training experience of physicians and their perception of the training quality pre and post Go-Live. Our team used Grounded Theory methodology to classify the interview information. Themes that emerged from the interviews included stress and anxiety, the desire for more realistic training environments tailored to specialty needs, and concerns about the duration of time between training and implementation. In future implementations, we recommend more data-rich test patients and the demonstration of real-world workflows during training.

Adoption of Electronic Dental Records: Examining the Influence of Practice Characteristics on Adoption in One State.

OBJECTIVE: Compared with medicine, less research has focused on adoption rates and factors contributing to the adoption of electronic dental records (EDRs) and certified electronic health records (EHRs) in the field of dentistry. We ran two multivariate models on EDR adoption and certification-capable EHR adoption to determine environmental and organizational factors associated with adoption. METHODS: We conducted telephone survey of a 10-item questionnaire using disproportionate stratified sampling procedure of 149 dental clinics in Tennessee in 2017 measuring adoption of dental information technology (IT) (EDRs and certification-capable EHRs) and practice characteristics, including region, rurality, specialty, and practice size. We used binomial logistic regression models to determine associations of adoption with predictor variables. RESULTS: A total of 77% of surveyed dental clinics in Tennessee had adopted some type of EDR system. When the definitions of certification capable were applied, the adoption rates in dental clinics dropped to 58%. A binomial logistic regression model for the effects of rurality, specialization, and practice size on the likelihood that a clinic would adopt an EHR product was statistically significant (chi-square (3) = 12.41, p = 0.0061). Of the three predictor variables, specialization and practice size were significant: Odds of adopting an EHR is 67% lower for specialists than for general dentists; and clinics with two or more practicing dentists were associated with a much greater likelihood of adopting an EHR-capable system (adjusted odds ratio = 3.09, p = 0.009). CONCLUSION: Findings from this study indicate moderate to high levels of overall dental IT adoption. However, adoption rates in dental clinics do remain lower than those observed in office-based physician practices in medicine. Specialization and practice size were significant predictors of EHR-capable system adoption. Efforts to increase EHR adoption in dentistry should be mindful of potential disparities in smaller practices and between dental specialties and generalists.

Common Consumer Health-Related Needs in the Pediatric Hospital Setting: Lessons from an Engagement Consultation Service.

BACKGROUND: Informed and engaged parents may influence outcomes for childhood illness. Understanding the needs of the caregivers of pediatric patients is a critical first step in promoting engagement in their child's care. In 2014, we developed an Engagement Consultation Service at the Monroe Carell Jr. Children's Hospital at Vanderbilt. This service determines the health-related needs of the caregivers of hospitalized children and makes educational or technology recommendations to meet those needs and support engagement. OBJECTIVES: This report describes the most common health-related needs identified in the caregivers of hospitalized pediatric patients and details the recommended interventions to meet those needs. METHODS: The most commonly reported consumer health-related needs from our 3-year experience with the Engagement Consultation Service were extracted from consultations notes. Each need was classified by semantic type using a taxonomy of consumer health needs. Typical recommendations for each need and their administration were detailed. RESULTS: The most frequently recognized needs involved communicating with health care providers after discharge, using medical devices, distinguishing between benign and concerning symptoms, knowing what questions to ask providers and remembering them, finding trustworthy sources of information online, understanding disease prognosis, and getting emotional support. A variety of apps, Web sites, printed materials, and online groups were recommended. CONCLUSION: The parents of hospitalized patients share several common health-related needs that can be addressed with educational and technology interventions. An inpatient Engagement Consultation Service provides a generalizable framework for identifying health-related needs and delivers tools to meet those needs and promote engagement during and after hospitalizations.

Clinicians' perspectives on and interest in participating in a clinical data research network across the Southeastern United States.

BACKGROUND: Partnerships between clinicians and researchers could increase the generalizability of research findings and increase uptake of research results across populations. Yet engaging clinicians in research is challenging. Clinical Data Research Networks (CDRNs) provide access to a broad array of clinical data, patients, clinicians and health systems by building on existing health records (EHRs) to facilitate multi-site community engaged research (CEnR). METHODS: A mixed-methods sequential explanatory design was employed. Sixty semi-structured interviews with clinicians from various disciplines and healthcare settings were conducted using five open-ended questions. Inductive content analysis was used to identify emerging themes in the data. RESULTS: We identified the following emerging themes: 1) Research with relevance and benefits to clinics and provider's patient population; 2) Difficulties of engaging in research with existing patient care demands; 3) Clear and continuous two-way communication about research, coordinated with provider and clinic needs; 4) Tailored compensation approaches meet provider preferences; 5) Increasing clinician awareness about Clinical Data Research Networks (CDRNs). CONCLUSION: Our interview study provides insight into community clinician perspectives on Clinical Data Research Networks, indicating motivations and challenges to research involvement including consequences of time spent on research participation, barriers to expanding research and meaningful involvement in research governance. Findings can be used to guide the development of strategies to better engage providers in research in clinical settings, which could ultimately improve patient outcomes.

Measuring non-administration of ordered medications in the pediatric inpatient setting.

OBJECTIVE: Medication compliance in inpatient settings shows some significant gaps for adult patients. In pediatric settings prescribing and other administration errors have been studied but missed doses have not been specifically studied in the pediatric inpatient setting. We intended to apply health information technology and data processing methods to study the medication compliance for pediatric patients at our institution. STUDY DESIGN: We collected medication ordering, dispensing, and administration data spanning 42 months (7/1/2010 through 12/31/2013) for pediatric inpatients admitted to a major tertiary pediatric hospital. We analyzed the orders for which either the corresponding administration record was missing or the records indicated non-administration. RESULTS: There were only 596 medication orders without corresponding administration records, accounting for less than 0.05% of 1.6 Million orders for 56,000 patients. There were 40,999 orders with corresponding administration records indicating non-administration (or less than 3% of all orders). Overall order compliance of the nursing staff was 97.35%, with another 2.6% of orders having a documented reason for non-administration The top two medication classes comprising the missed and non-administered orders were "Alimentary tract and metabolism drugs" and "Nervous system drugs". CONCLUSION: Measurement of medication compliance is an important quality measure of patient safety and quality of care. Our study found a small proportion of non-administered medication orders and discovered corresponding reasons illustrating how health information technology can help to measure the quality of the medication process from ordering and dispensing to administration at a major healthcare institution.

Next generation pathways into biomedical informatics: lessons from 10 years of the Vanderbilt Biomedical Informatics Summer Internship Program.

OBJECTIVES: To examine roles for summer internship programs in expanding pathways into biomedical informatics, based on 10 years of the Vanderbilt Department of Biomedical Informatics (DBMI) Summer Research Internship Program. MATERIALS AND METHODS: Vanderbilt DBMI's internship program is a research-intensive paid 8-10 week program for high school, undergraduate, and graduate students. The program is grounded in a "Windows, Mirrors, and Open Doors" educational framework, and is guided by an evolving set of design principles, including providing meaningful research experiences, applying a multi-factor approach to diversity, and helping interns build peer connections. RESULTS: Over 10 years, 90 individuals have participated in the internship program, with nine students participating for more than one summer. Of 90 participants, 38 were women and 52 were men. Participants represented a range of racial/ethnic groups. A total of 39 faculty members have served as primary mentor for one or more interns. Five key lessons emerged from our program experience: Festina Lente ("Make haste slowly"), The Power of Community, Learning by Doing, Thoughtful Partnerships Lead to Innovation, and The Whole is More Than the Sum of Its Parts. DISCUSSION: Based on our experience, we suggest that internship programs should become a core element of the biomedical informatics educational ecosystem. Continued development and growth of this important educational outreach approach requires stable funding sources and building connections between programs to share best practices. CONCLUSION: Internship programs can play a substantial role in the biomedical informatics educational ecosystem, helping introduce individuals to the field earlier in their educational trajectories.

A Randomized Trial Comparing Classical Participatory Design to VandAID, an Interactive CrowdSourcing Platform to Facilitate User-centered Design.

BACKGROUND: Early involvement of stakeholders in the design of medical software is particularly important due to the need to incorporate complex knowledge and actions associated with clinical work. Standard user-centered design methods include focus groups and participatory design sessions with individual stakeholders, which generally limit user involvement to a small number of individuals due to the significant time investments from designers and end users. OBJECTIVES: The goal of this project was to reduce the effort for end users to participate in co-design of a software user interface by developing an interactive web-based crowdsourcing platform. METHODS: In a randomized trial, we compared a new web-based crowdsourcing platform to standard participatory design sessions. We developed an interactive, modular platform that allows responsive remote customization and design feedback on a visual user interface based on user preferences. The responsive canvas is a dynamic HTML template that responds in real time to user preference selections. Upon completion, the design team can view the user's interface creations through an administrator portal and download the structured selections through a REDCap interface. RESULTS: We have created a software platform that allows users to customize a user interface and see the results of that customization in real time, receiving immediate feedback on the impact of their design choices. Neonatal clinicians used the new platform to successfully design and customize a neonatal handoff tool. They received no specific instruction and yet were able to use the software easily and reported high usability. CONCLUSIONS: VandAID, a new web-based crowdsourcing platform, can involve multiple users in user-centered design simultaneously and provides means of obtaining design feedback remotely. The software can provide design feedback at any stage in the design process, but it will be of greatest utility for specifying user requirements and evaluating iterative designs with multiple options.

Medication Management: The Macrocognitive Workflow of Older Adults With Heart Failure.

BACKGROUND: Older adults with chronic disease struggle to manage complex medication regimens. Health information technology has the potential to improve medication management, but only if it is based on a thorough understanding of the complexity of medication management workflow as it occurs in natural settings. Prior research reveals that patient work related to medication management is complex, cognitive, and collaborative. Macrocognitive processes are theorized as how people individually and collaboratively think in complex, adaptive, and messy nonlaboratory settings supported by artifacts. OBJECTIVE: The objective of this research was to describe and analyze the work of medication management by older adults with heart failure, using a macrocognitive workflow framework. METHODS: We interviewed and observed 61 older patients along with 30 informal caregivers about self-care practices including medication management. Descriptive qualitative content analysis methods were used to develop categories, subcategories, and themes about macrocognitive processes used in medication management workflow. RESULTS: We identified 5 high-level macrocognitive processes affecting medication management-sensemaking, planning, coordination, monitoring, and decision making-and 15 subprocesses. Data revealed workflow as occurring in a highly collaborative, fragile system of interacting people, artifacts, time, and space. Process breakdowns were common and patients had little support for macrocognitive workflow from current tools. CONCLUSIONS: Macrocognitive processes affected medication management performance. Describing and analyzing this performance produced recommendations for technology supporting collaboration and sensemaking, decision making and problem detection, and planning and implementation.

Realizing the Potential of Patient Engagement: Designing IT to Support Health in Everyday Life.

Maintaining health or managing a chronic condition involves performing and coordinating potentially new and complex tasks in the context of everyday life. Tools such as reminder apps and online health communities are being created to support patients in carrying out these tasks. Research has documented mixed effectiveness and problems with continued use of these tools, and suggests that more widespread adoption may be aided by design approaches that facilitate integration of eHealth technologies into patients' and family members' daily routines. Given the need to augment existing methods of design and implementation of eHealth tools, this contribution discusses frameworks and associated methods that engage patients and explore contexts of use in ways that can produce insights for eHealth designers.