Characterizing barriers to closing cross-institutional referral loops: Workflow and information flow analysis.

The specialty referral process consists of primary care clinicians referring patients to specialty consultants. This care transition requires effective care coordination and health information exchange between care teams; however, breakdowns in workflow and information flow impede "closing the referral loop" and delay or prevent referrers from receiving the consultant's "visit notes," particularly in cross-institutional referrals. This study aimed to describe and map the referral process as it occurs in clinics and identify and characterize work system barriers affecting its performance. Referrers and consultants were interviewed about their perceived workflows, barriers, and clinical outcomes to inform a workflow analysis.

Consultants' and referrers' perceived barriers to closing the cross-institutional referral loop, and perceived impact on clinical care.

BACKGROUND: Cross-institutional (external) referrals are prone to communication breakdowns, increasing patient safety risks, clinician burnout, and healthcare costs. To close these external referral loops, referring primary care physicians (PCPs) need to receive patient information from consultants at different healthcare institutions. Although existing studies investigated the early phases of external referral loops, we lack sufficient knowledge about the closing phases of these loops. This knowledge could allow health care institutions to improve care coordination and rates of closed referral loops by implementing socio-technical interventions for patient information exchange throughout a referral loop. Human factors engineering (HFE) provides a systematic approach to advance our understanding of barriers perceived by physicians. Using HFE, our objective was to characterize referring and consulting physicians' barriers to closing referral loops and implications for care. METHODS: This qualitative cross-sectional study included semi-structured interviews with referrers and external consultants. We used the Systems Engineering Initiative for Patient Safety 2.0 framework to conduct rapid qualitative analyses, determining perceived barriers and related implications. Main measures were consultants' and referrers' perceptions of, and experiences with, barriers to external referrals. RESULTS: Six referring PCPs and 12 consultants participated from two healthcare systems and four medical specialties. Physicians perceived three main barriers in external referrals: receipt of excessive and unnecessary faxed documents, missing or delayed documentation, and organizational policies regarding information privacy interfering with closing the loop. Compared to internal referrals, physicians reported increased staff burden, patient frustration, and delays in diagnosis with external referrals. Consultants reported the ability to provide the same level of care to patients with internal or external referrals. However, consultants described communication breakdowns that prohibited confirmation of follow-up plan retrieval, initiation, or effectiveness. CONCLUSION: Physicians reported technological and organizational barriers to closing cross-institutional referral loops. Promises of HIE technology for external referrals have not fully materialized. Among physicians and patients, retrieval and exchange of medical information increases perceived workload, burden, and frustration. These increases are not accurately captured by traditional organizational metrics. This study provides evidence that informs future human factors engineering research to address perceived barriers and guide future HIE design or implementation.

Technology caregiver intervention for Alzheimer's disease (I-CARE): Feasibility and preliminary efficacy of Brain CareNotes.

BACKGROUND: The primary aim of the current pilot study was to examine enrollment rate, data completion, usability, acceptance and use of a mobile telehealth application, Brain CareNotes. A secondary aim was to estimate the application's effect in reducing caregiver burden and behavioral and psychological symptoms related to dementia (BPSD). METHODS: Patient-caregiver dyads (n = 53) were recruited and randomized to intervention and control groups. Assessment of usability, acceptance, BPSD symptoms, and caregiver burden were collected at baseline, 3- and 6-month follow-up. RESULTS: The enrollment rate was acceptable despite pandemic related challenges (53/60 target recruitment sample). Among randomized individuals, there was a retention rate of 85% and data completion was attained for 81.5% of those allocated to usual care and 88.5% of those allocated to Brain CareNotes. Mean caregiver-reported app usability at 6 months was 72.5 (IQR 70.0-90.0) on the System Usability Scale-considered "Good to Excellent"-and user acceptance was reasonable as indicated by 85%-90% of caregivers reporting they would intend to use the app to some degree in the next 6 months, if able. Regarding intervention effect, although differences in outcome measures between the groups were not statistically significant, compared to baseline, we found a reduction of caregiver burden (NPI-Caregiver Distress) of 1.0 at 3 months and 0.7 at 6 months for those in the intervention group. BPSD (NPI Total Score) was also reduced from baseline by 4.0 at 3 months and by 0.5 at 6 months. CONCLUSIONS: Brain CareNotes is a highly scalable, usable and acceptable mobile caregiver intervention. Future studies should focus on testing Brain CareNotes on a larger sample size to examine efficacy of reducing caregiver burden and BPSD.

Continuous Glucose Monitoring and Other Wearable Devices to Assess Hypoglycemia among Older Adult Outpatients with Diabetes Mellitus.

BACKGROUND: Hypoglycemia (HG) causes symptoms that can be fatal, and confers risk of dementia. Wearable devices can improve measurement and feedback to patients and clinicians about HG events and risk. OBJECTIVES: The aim of the study is to determine whether vulnerable older adults could use wearables, and explore HG frequency over 2 weeks. METHODS: First, 10 participants with diabetes mellitus piloted a continuous glucometer, physical activity monitor, electronic medication bottles, and smartphones facilitating prompts about medications, behaviors, and symptoms. They reviewed graphs of glucose values, and were asked about the monitoring experience. Next, a larger sample (N = 70) wore glucometers and activity monitors, and used the smartphone and bottles, for 2 weeks. Participants provided feedback about the devices. Descriptive statistics summarized demographics, baseline experiences, behaviors, and HG. RESULTS: In the initial pilot, 10 patients aged 50 to 85 participated. Problems addressed included failure of the glucometer adhesive. Patients sought understanding of graphs, often requiring some assistance with interpretation. Among 70 patients in subsequent testing, 67% were African-American, 59% were women. Nearly one-fourth (23%) indicated that they never check their blood sugars. Previous HG was reported by 67%. In 2 weeks of monitoring, 73% had HG (glucose ≤70 mg/dL), and 42% had serious, clinically significant HG (glucose under 54 mg/dL). Eight patients with HG also had HG by home-based blood glucometry. Nearly a third of daytime prompts were unanswered. In 24% of participants, continuous glucometers became detached. CONCLUSION: Continuous glucometry occurred for 2 weeks in an older vulnerable population, but devices posed wearability challenges. Most patients experienced HG, often serious in magnitude. This suggests important opportunities to improve wearability and decrease HG frequency among this population.

Electronic Health Records' Support for Primary Care Physicians' Situation Awareness: A Metanarrative Review.

OBJECTIVE: Situation awareness (SA) refers to people's perception and understanding of their dynamic environment. In primary care, reduced SA among physicians increases errors in clinical decision-making and, correspondingly, patients' risk of experiencing adverse outcomes. Our objective was to understand the extent to which electronic health records (EHRs) support primary care physicians (PCPs)' SA during clinical decision-making. METHOD: We conducted a metanarrative review of papers in selected academic databases, including CINAHL and MEDLINE. Eligible studies included original peer-reviewed research published between January 2012 and August 2020 on PCP-EHR interactions. We iteratively queried, screened, and summarized literature focused on EHRs supporting PCPs' clinical decision-making and care management for adults. Then, we mapped findings to an established SA framework to classify external factors (individual, task, and system) affecting PCPs' levels of SA (1-Perception, 2-Comprehension, and 3-Projection) and identified SA barriers. RESULTS: From 1504 articles identified, we included and synthesized 19 studies. Study designs were largely noninterventional. Studies described EHR workflow misalignments, usability issues, and communication challenges. EHR information, including lab results and care plans, was characterized as incomplete, untimely, or irrelevant. Unmet information needs made it difficult for PCPs to obtain even basic SA, Level 1 SA. Prevalent barriers to PCPs developing SA with EHRs were errant mental models, attentional tunneling, and data overload. CONCLUSION: Based on our review, EHRs do not support the development of higher levels of SA among PCPs. Review findings suggest SA-oriented design processes for health information technology could improve PCPs' SA, satisfaction, and decision-making.

Improving Care for People Living With Dementia and Diabetes: Applying the Human-Centered Design Process to Continuous Glucose Monitoring.

People with Alzheimer's disease or related dementias and diabetes mellitus (ADRD-DM) are at high risk for hypoglycemic events. Their cognitive impairment and psychosocial situation often hinder detection of hypoglycemia. Extending use and benefits of continuous glucose monitoring (CGM) to people with ADRD-DM could improve hypoglycemia detection, inform care, and reduce adverse events. However, cognitive impairment associated with ADRD presents unique challenges for CGM use. This commentary proposes applying the human-centered design process to CGM, investigating design solutions or interventions needed to integrate CGM into the health care of patients with ADRD-DM. With this process, we can identify and inform CGM designs for people with ADRD-DM, broadening CGM access, increasing detection and treatment of the silent threat posed by hypoglycemia.

Electronic Co-design (ECO-design) Workshop for Increasing Clinician Participation in the Design of Health Services Interventions: Participatory Design Approach.

BACKGROUND: Participation from clinician stakeholders can improve the design and implementation of health care interventions. Participatory design methods, especially co-design methods, comprise stakeholder-led design activities that are time-consuming. Competing work demands and increasing workloads make clinicians' commitments to typical participatory methods even harder. The COVID-19 pandemic further exacerbated barriers to clinician participation in such interventions. OBJECTIVE: The aim of this study was to explore a web-based participatory design approach to conduct economical, electronic co-design (ECO-design) workshops with primary care clinicians. METHODS: We adapted traditional in-person co-design workshops to web-based delivery and adapted co-design workshop series to fit within a single 1-hour session. We applied the ECO-design workshop approach to codevelop feedback interventions regarding abnormal test result follow-up in primary care. We conducted ECO-design workshops with primary care clinicians at a medical center in Southern Texas, using videoconferencing software. Each workshop focused on one of three types of feedback interventions: conversation guide, email template, and dashboard prototype. We paired electronic materials and software features to facilitate participant interactions, prototyping, and data collection. The workshop protocol included four main activities: problem identification, solution generation, prototyping, and debriefing. Two facilitators were assigned to each workshop and one researcher resolved technical problems. After the workshops, our research team met to debrief and evaluate workshops. RESULTS: A total of 28 primary care clinicians participated in our ECO-design workshops. We completed 4 parallel workshops, each with 5-10 participants. We conducted traditional analyses and generated a clinician persona (ie, representative description) and user interface prototypes. We also formulated recommendations for future ECO-design workshop recruitment, technology, facilitation, and data collection. Overall, our adapted workshops successfully enabled primary care clinicians to participate without increasing their workload, even during a pandemic. CONCLUSIONS: ECO-design workshops are viable, economical alternatives to traditional approaches. This approach fills a need for efficient methods to involve busy clinicians in the design of health care interventions.

Emotional distress, stress, anxiety, and the impact of the COVID-19 pandemic on early- to mid-career women in healthcare sciences research.

Objectives: The main objective of this study was to report stress and anxiety levels during the COVID-19 pandemic on early- to mid-career women researchers in healthcare sciences research and determine the associated factors. Methods: A 50-item self-administered internet questionnaire was developed using a mix of Likert-type scales and open-ended response questions. The survey was distributed June 10-August 3, 2020. Anxiety and stress as well as personal/family demands were assessed through validated measures (Patient Reported Outcomes Measurement Information System [PROMIS]-Anxiety Short Form and Perceived Stress Scale [PSS]) and open-ended responses. Results: One hundred and fifty-one early-career women in healthcare sciences research completed the survey; mean respondent age was 37.3 ± 5.2 years; and all had a college degree or higher, 50.3% holding a PhD and 35.8% MD. Race and ethnicity were reported in 128; the majority were White (74.0%). One-third (31.2%) reported being "very much" concerned about reaching their research productivity goals and 30.1% were "very much" concerned about academic promotion and tenure. Fifty percent reported a "moderate" PROMIS anxiety score and 72.1% reported a "moderate" PSS score. For the open-ended responses, 65.6% reported a worry about their professional goals because of the COVID-19 pandemic. Major concerns revolved around finances, childcare, and job security. Conclusions: Throughout the pandemic, early- and mid-career women in healthcare sciences research have reported moderate to high overall stress, anxiety, and worries. These concerns appear related to household settings, additional responsibilities, financial concerns, and reduced research productivity. Institutions and funding agencies should take these concerns into consideration and offer support.

Qualitative Analysis of Team Communication with a Clinical Texting System at a Midwestern Academic Hospital.

BACKGROUND: Hospitals are increasingly replacing pagers with clinical texting systems that allow users to use smartphones to send messages while maintaining compliance for privacy and security. As more institutions adopt such systems, the need to understand the impact of such transitions on team communication becomes ever more significant. METHODS: We conducted focus groups with hospitalists and individual interviews with nurses at one academic medical center in the Midwest. All interviews and focus groups were audiorecorded, transcribed, and deidentified for analysis. All transcripts and notes were independently read by two members of the research team and coded for themes. RESULTS: Twenty-one hospitalists and eight nurses participated in the study. Although study participants spoke favorably of texting, they identified more dissatisfactions with texting than benefits. There were disagreements regarding appropriate texting practices both within and between the hospitalists and nurses. CONCLUSION: Despite the benefits of texting, there is room for improving team communication and understanding in the realm of clinical texting. A lack of shared understanding regarding when and how to use texting may require long-term solutions that address teamwork and appropriateness.

Clinician Perspectives on Unmet Needs for Mobile Technology Among Hospitalists: Workflow Analysis Based on Semistructured Interviews.

BACKGROUND: The hospitalist workday is cognitively demanding and dominated by activities away from patients' bedsides. Although mobile technologies are offered as solutions, clinicians report lower expectations of mobile technology after actual use. OBJECTIVE: The purpose of this study is to better understand opportunities for integrating mobile technology and apps into hospitalists' workflows. We aim to identify difficult tasks and contextual factors that introduce inefficiencies and characterize hospitalists' perspectives on mobile technology and apps. METHODS: We conducted a workflow analysis based on semistructured interviews. At a Midwestern US medical center, we recruited physicians and nurse practitioners from hospitalist and inpatient teaching teams and internal medicine residents. Interviews focused on tasks perceived as frequent, redundant, and difficult. Additionally, participants were asked to describe opportunities for mobile technology interventions. We analyzed contributing factors, impacted workflows, and mobile app ideas. RESULTS: Over 3 months, we interviewed 12 hospitalists. Participants collectively identified chart reviews, orders, and documentation as the most frequent, redundant, and difficult tasks. Based on those tasks, the intake, discharge, and rounding workflows were characterized as difficult and inefficient. The difficulty was associated with a lack of access to electronic health records at the bedside. Contributing factors for inefficiencies were poor usability and inconsistent availability of health information technology combined with organizational policies. Participants thought mobile apps designed to improve team communications would be most beneficial. Based on our analysis, mobile apps focused on data entry and presentation supporting specific tasks should also be prioritized. CONCLUSIONS: Based on our results, there are prioritized opportunities for mobile technology to decrease difficulty and increase the efficiency of hospitalists' workflows. Mobile technology and task-specific mobile apps with enhanced usability could decrease overreliance on hospitalists' memory and fragmentation of clinical tasks across locations. This study informs the design and implementation processes of future health information technologies to improve continuity in hospital-based medicine.

Dashboards for visual display of patient safety data: a systematic review.

BACKGROUND: Methods to visualise patient safety data can support effective monitoring of safety events and discovery of trends. While quality dashboards are common, use and impact of dashboards to visualise patient safety event data remains poorly understood. OBJECTIVES: To understand development, use and direct or indirect impacts of patient safety dashboards. METHODS: We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched PubMed, EMBASE and CINAHL for publications between 1 January 1950 and 30 August 2018 involving use of dashboards to display data related to safety targets defined by the Agency for Healthcare Research and Quality's Patient Safety Net. Two reviewers independently reviewed search results for inclusion in analysis and resolved disagreements by consensus. We collected data on development, use and impact via standardised data collection forms and analysed data using descriptive statistics. RESULTS: Literature search identified 4624 results which were narrowed to 33 publications after applying inclusion and exclusion criteria and consensus across reviewers. Publications included only time series and case study designs and were inpatient focused and emergency department focused. Information on direct impact of dashboards was limited, and only four studies included informatics or human factors principles in development or postimplementation evaluation. DISCUSSION: Use of patient-safety dashboards has grown over the past 15 years, but impact remains poorly understood. Dashboard design processes rarely use informatics or human factors principles to ensure that the available content and navigation assists task completion, communication or decision making. CONCLUSION: Design and usability evaluation of patient safety dashboards should incorporate informatics and human factors principles. Future assessments should also rigorously explore their potential to support patient safety monitoring including direct or indirect impact on patient safety.

Building cohesion in distributed telemedicine teams: findings from the Department of Veterans Affairs National Telestroke Program.

BACKGROUND: As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identified cohesion-related factors in program development and support. METHODS: We studied the virtual hub of stroke specialists employed by the NTSP. Semi-structured, confidential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and team cohesion, and we identified factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction. RESULTS: Of 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with co-located colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP. CONCLUSION: A virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promote cohesion in distributed telemedicine teams.

Gains, losses, and uncertainties from computerizing referrals and consultations.

Consultations entail transitions in care between referrers and consultants, as patients visit different clinicians and care sites. This complex process has been consistently prone to communication breakdowns. Despite expectations and benefits of electronic health records (EHRs), incomplete, vague, or inappropriate referrals continue to hinder consultations; referrals can be sent to the wrong specialty service; and consultation findings frequently fail to reach referrers. Due to the inadequate support of interpersonal communication afforded by EHRs, these issues persist. Important aspects of ergonomics and human factors engineering frequently appear overlooked during the design and implementation of EHRs. Usability issues have contributed to delays in medical diagnosis, treatment, and follow-up. Some of these delays contribute to patient harms. Our multidisciplinary team of clinicians and ergonomics professionals reflects on referral and consultation. We describe how computerization in healthcare should benefit from approaches informed and developed through applied ergonomics and human factors.

Cognitive requirements for primary care providers during the referral process: Information needed from and interactions with an electronic health record system.

OBJECTIVES: This study sought to identify and describe the cognitive requirements and associated information needs of referring primary care providers (PCPs) during the referral process as well as characterize referring PCPs' experiences with current health information technology. MATERIALS AND METHODS: We interviewed 62 referring PCPs. Our four-member analysis team used hierarchical task analysis to construct a goal-directed hierarchy. We utilized extensions of the task analysis to describe PCPs' common experiences with health information technologies throughout the referral process. RESULTS: The resultant goal hierarchy includes one main goal (Referral for Additional Care), two sub-goals (Assess Patient's Condition and Manage Referrals), and four major tasks with respective decisions (What consultation is warranted; What information should I provide; What additional action is needed; and How to integrate specialists' findings). Approximately 22 information needs were commonly identified and PCPs described their use of various sources - other PCPs, electronic health records, chat software, and paper- to satisfy those information needs. CONCLUSION: Cognitive demand for referring PCPs is high throughout the referral process. They have to search, identify, compose, track, and integrate information across multiple screens, systems, and people. Existing interfaces do not adequately support the communication, information exchange, or care coordination related to the referral process. Results from this study provide an important foundation for developing patient-centered displays that support PCPs' decision-making process and reduce cognitive challenges.

Comparative usability evaluation of consultation order templates in a simulated primary care environment.

Communication breakdowns in the referral process negatively impact clinical workflow and patient safety. There is a lack of evidence demonstrating the impact of published design recommendations addressing contributing issues with consultation order templates. This study translated the recommendations into a computer-based prototype and conducted a comparative usability evaluation. With a scenario-based simulation, 30 clinicians (referrers) participated in a within-group, counterbalanced experiment comparing the prototype with their present electronic order entry system. The prototype significantly increased satisfaction (Cohen's d = 1.80, 95% CI [1.19, 2.41], p < .001), and required significantly less mental effort (d = 0.67 [0.14, 1.20], p < .001). Regarding efficiency, the prototype required significantly fewer mouse clicks (mean difference = 29 clicks, p < .001). Although overall task time did not differ significantly (d = -0.05 [-0.56, 0.47]), the prototype significantly quickened identification of the appropriate specialty clinic (mean difference = 12 s, d = 0.98 [0.43, 1.52], p < .001). The experimental evidence demonstrated that clinician-centered interfaces significantly improved system usability during ordering of consultations.

A cognitive systems engineering design approach to improve the usability of electronic order forms for medical consultation.

BACKGROUND: During medical referrals, communication barriers between referring and consulting outpatient clinics delay patients' access to health care. One notable opportunity for reducing these barriers is improved usefulness and usability of electronic medical consultation order forms. The cognitive systems engineering (CSE) design approach focuses on supporting humans in managing cognitive complexity in sociotechnical systems. Cognitive complexity includes communication, decision-making, problem solving, and planning. OBJECTIVE: The objective of this research was to implement a CSE design approach to develop a template that supports the cognitive needs of referring clinicians and improves referral communication. METHODS: We conducted interviews and observations with primary care providers and specialists at two major tertiary, urban medical facilities. Using qualitative analysis, we identified cognitive requirements and design guidelines. Next, we designed user interface (UI) prototypes and compared their usability with that of a currently implemented UI at a major Midwestern medical facility. RESULTS: Physicians' cognitive challenges were summarized in four cognitive requirements and 13 design guidelines. As a result, two UI prototypes were developed to support order template search and completion. To compare UIs, 30 clinicians (referrers) participated in a consultation ordering simulation complemented with the think-aloud elicitation method. Oral comments about the UIs were coded for both content and valence (i.e., positive, neutral, or negative). Across 619 comments, the odds ratio for the UI prototype to elicit higher-valenced comments than the implemented UI was 13.5 (95% CI = [9.2, 19.8]), p < .001. CONCLUSION: This study reinforced the significance of applying a CSE design approach to inform the design of health information technology. In addition, knowledge elicitation methods enabled identification of physicians' cognitive requirements and challenges when completing electronic medical consultation orders. The resultant knowledge was used to derive design guidelines and UI prototypes that were more useful and usable for referring physicians. Our results support the implementation of a CSE design approach for electronic medical consultation orders.

Investigating the need for clinicians to use tablet computers with a newly envisioned electronic health record.

OBJECTIVE: The Veterans Health Administration (VHA) has deployed a large number of tablet computers in the last several years. However, little is known about how clinicians may use these devices with a newly planned Web-based electronic health record (EHR), as well as other clinical tools. The objective of this study was to understand the types of use that can be expected of tablet computers versus desktops. METHODS: Semi-structured interviews were conducted with 24 clinicians at a Veterans Health Administration (VHA) Medical Center. RESULTS: An inductive qualitative analysis resulted in findings organized around recurrent themes of: (1) Barriers, (2) Facilitators, (3) Current Use, (4) Anticipated Use, (5) Patient Interaction, and (6) Connection. CONCLUSIONS: Our study generated several recommendations for the use of tablet computers with new health information technology tools being developed. Continuous connectivity for the mobile device is essential to avoid interruptions and clinician frustration. Also, making a physical keyboard available as an option for the tablet was a clear desire from the clinicians. Larger tablets (e.g., regular size iPad as compared to an iPad mini) were preferred. Being able to use secure messaging tools with the tablet computer was another consistent finding. Finally, more simplicity is needed for accessing patient data on mobile devices, while balancing the important need for adequate security.