ACI - Applied Clinical Informatics Journal

30/10/2024

The Leaders in Informatics, Quality, and Systems (LInQS) Fellowship

Heather Hallman , Jonathan Pell , P. Michael Ho , Brian Montague , Lisa Schilling , Amber Sieja , Karen Ream , Tyler Anstett

Background Leaders in Informatics, Quality, and Systems (LInQS) is a non-ACGME (Accreditation Council for Graduate Medical Education)-accredited 2-year training program developed to enhance training in the fields of health care delivery, quality improvement (QI), clinical informatics, and leadership.

Methods This single-institution 2-year longitudinal training program grounded in QI and informed by leadership and clinical informatics includes didactics, coaching, and mentorship, all centered around individualized QI projects. The program has been available to sub-specialty fellows, advanced practice providers, and physicians.

Results From 2019 to 2023, 32 fellows have been accepted into the program with 13 graduates and 16 currently enrolled. Fellows have been predominately female, physicians, and from multiple specialties but predominantly hospital medicine. Fellows' evaluations of the fellowship are highly positive, rating the didactics and mentorship aspects of the curriculum most favorably. Most fellows' projects utilized informatics solutions including clinical decision support tools to increase quality of care, improve patient outcomes, and reduce costs of care resulting in manuscript publications, national presentations, and a national specialty society award. Since matriculation, 50% of fellows received certification as Epic Physician Builders and 34% received leadership positions in clinical informatics, quality, and education.

Conclusion Our experience supports the need to provide health care providers more expansive training in the areas of QI, clinical informatics, and leadership for improving health care delivery. Additional in-depth knowledge and experience in these fields may produce and benefit leaders in these fields.

Keywords
clinical informatics - quality improvement - education - leadership

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0044-1790550

30/10/2024

Multitasking during Medication Management in a Nursing Home: A Time Motion Study

Heather Hallman, Jonathan Pell, P. Michael Ho, Brian Montague, Lisa Schilling, Amber Sieja, Karen Ream, Tyler Anstett

Background Leaders in Informatics, Quality, and Systems (LInQS) is a non-ACGME (Accreditation Council for Graduate Medical Education)-accredited 2-year training program developed to enhance training in the fields of health care delivery, quality improvement (QI), clinical informatics, and leadership.
Methods This single-institution 2-year longitudinal training program grounded in QI and informed by leadership and clinical informatics includes didactics, coaching, and mentorship, all centered around individualized QI projects. The program has been available to sub-specialty fellows, advanced practice providers, and physicians.
Results From 2019 to 2023, 32 fellows have been accepted into the program with 13 graduates and 16 currently enrolled. Fellows have been predominately female, physicians, and from multiple specialties but predominantly hospital medicine. Fellows' evaluations of the fellowship are highly positive, rating the didactics and mentorship aspects of the curriculum most favorably. Most fellows' projects utilized informatics solutions including clinical decision support tools to increase quality of care, improve patient outcomes, and reduce costs of care resulting in manuscript publications, national presentations, and a national specialty society award. Since matriculation, 50% of fellows received certification as Epic Physician Builders and 34% received leadership positions in clinical informatics, quality, and education.
Conclusion Our experience supports the need to provide health care providers more expansive training in the areas of QI, clinical informatics, and leadership for improving health care delivery. Additional in-depth knowledge and experience in these fields may produce and benefit leaders in these fields.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0044-1790550

30/10/2024

Defining Documentation Burden (DocBurden) and Excessive DocBurden for All Health Professionals: A Scoping Review

Deborah R. Levy, Jennifer B. Withall, Rebecca G. Mishuris, Victoria Tiase, Courtney Diamond, Brian Douthit, Monika Grabowska, Rachel Y. Lee, Amanda J. Moy, Patricia Sengstack, Julia Adler-Milstein, Don Eugene Detmer, Kevin B. Johnson, James J. Cimino, Sarah Corley, Judy Murphy, S. Trent Rosenbloom, Kenrick Cato, Sarah C. Rossetti

Objectives Efforts to reduce documentation burden (DocBurden) for all health professionals (HP) are aligned with national initiatives to improve clinician wellness and patient safety. Yet DocBurden has not been precisely defined, limiting national conversations and rigorous, reproducible, and meaningful measures. Increasing attention to DocBurden motivated this work to establish a standard definition of DocBurden, with the emergence of excessive DocBurden as a term.
Methods We conducted a scoping review of DocBurden definitions and descriptions, searching six databases for scholarly, peer-reviewed, and gray literature sources, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extensions for Scoping Review guidance. For the concept clarification phase of work, we used the American Nursing Informatics Association's Six Domains of Burden Framework.
Results A total of 153 articles were included based on a priori criteria. Most articles described a focus on DocBurden, but only 18% (n = 28) provided a definition. We define excessive DocBurden as the stress and unnecessarily heavy work an HP or health care team experiences when usability of documentation systems and documentation activities (i.e., generation, review, analysis, and synthesis of patient data) are not aligned in support of care delivery. A negative connotation was attached to burden without a neutral state in included sources, which does not align with dictionary definitions of burden.
Conclusion Existing literature does not distinguish between a baseline or required task load to conduct patient care resulting from usability issues (DocBurden), and the unnecessarily heavy tasks and requirements that contribute to excessive DocBurden. Our definition of excessive DocBurden explicitly acknowledges this distinction, to support development of meaningful measures for understanding and intervening on excessive DocBurden locally, nationally, and internationally.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/a-2385-1654

30/10/2024

Pedagogical Principles in Implementing a Data Visualization Project in an Undergraduate Public Health Informatics Course

John Robert Bautista

Background The Applied Public Health Informatics Competency Model lists “data analysis, visualization, and reporting” as one of the eight competencies when teaching public health informatics. Thus, public health informatics students need to develop knowledge and skills in visualizing public health data. Unfortunately, there is limited work that discusses pedagogical principles that could guide the implementation of pedagogical activities related to data visualization in public health informatics.
Objective This study aimed to introduce, discuss, and reflect on pedagogical principles that were implemented for a data visualization project in an undergraduate public health informatics course.
Methods A reflective teaching approach was used to guide the discussion and reflection on how pedagogical principles were implemented for a data visualization project in an undergraduate public health informatics course. The generic implementation framework (i.e., preimplementation, implementation, and postimplementation) was used to organize the discussion of the course's implementation.
Results Four pedagogical principles were implemented as part of a data visualization project in an undergraduate public health informatics course: scaffolding (i.e., outputs built on top of each other), constructivism (i.e., students apply knowledge and work in teams to create a dashboard), critical consciousness (i.e., embedding social determinants of health (SDOH) in their dashboard), and equity and inclusion (i.e., using a free data visualization software that is easy to use for beginners and is used by public health institutions). Postimplementation reflection revealed areas of improvement, such as enhancing group advising, adding more SDOH variables in the dashboard, and plans for scalability.
Conclusion A data visualization project in an undergraduate public health informatics course could benefit from implementing multiple pedagogical principles. Overall, creating dashboards can be a learning tool to enhance data visualization skills among undergraduate public health informatics students. Dashboards can also emphasize the impact of health disparities and inequities in public health by incorporating the principles of SDOH.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/a-2385-1544

23/10/2024

Multitasking during Medication Management in a Nursing Home: A Time Motion Study

Yu Jin Kang, Christine A. Mueller, Joseph E. Gaugler, Karen A. Monsen

Background Multitasking, defined as performing two or more interventions simultaneously, increases the cognitive burden of clinicians. This may, in turn, lead to higher risk of medication and procedural errors. Time motion study (TMS) data for nurses in nursing homes revealed an extensive amount of multitasking while managing medications. Further investigation of multitasked nursing interventions will provide a foundation for optimizing medication management workflows.
Objectives Using a continuous observational TMS method, this study aimed to describe pairs of multitasked nursing interventions associated with medication management interventions, including preparing and administering medications, assessing medication effects, instructing on medications, and documenting medication administration.
Methods An external nurse observer used 57 predefined Omaha System nursing interventions embedded within TimeCaT (version 3.9), TMS data recording software to collect observation data in a single nursing home. A total of 120 hours of time-stamped observation data from nine nurses were downloaded from TimeCaT and analyzed using descriptive and inferential statistics.
Results The majority (74%) of medication management interventions were multitasked, resulting in 2,003 pairs of multitasked interventions. Of the 57 Omaha System nursing interventions, 35 were involved in these multitasking pairs. When nurses multitasked, the average duration of medication preparation was longer (non-multitasked: 81 seconds; multitasked: 162 seconds, p < 0.05), while the average duration of medication administration record documentation was shorter (non-multitasked: 93 seconds; multitasked: 66 seconds, p < 0.05).
Conclusion The findings reveal the complexity of medication management in nursing homes with numerous and diverse multitasking pairs. Findings provide a platform for in-depth study of medication management multitasking in the clinical context, and inform future efforts to create clinical and informatics solutions to optimize medication management workflow. This method may be also applied to examine medication management and multitasking in other clinical settings.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/a-2379-7206

23/10/2024

From Headache to Handled: Advanced In-Basket Management System in Primary Care Clinics Reduces Provider Workload Burden and Self-Reported Burnout

LaPortia Smith, Wendy Kirk, Monica M. Bennett, Kenneth Youens, Jason Ramm

Background The electronic health record (EHR) has been associated with provider burnout, exacerbated by increasing In-Basket burden.
Objectives We sought to study the impact of implementing a team-based approach to In-Basket management on a series of primary care ambulatory sites.
Methods We performed a workflow analysis of the transition to the Advanced In-Basket Management (AIM) nurse team triage for six family medicine clinic locations in a large health system. We abstracted and analyzed associated provider workflow metrics from our EHR. We conducted a postintervention provider survey on satisfaction with the AIM project and provider burnout.
Results The AIM project was implemented in six family medicine clinics after provider townhalls and workgroup development. A nurse team curriculum was created using the principles of “maturing the message” before sending it to a provider and “only handle it once” to improve response efficiency. Provider workload metrics abstracted from the EHR demonstrated 12.2 fewer In-Basket messages per provider per day (p < 0.05), 6.3 fewer minutes per provider per day worked outside scheduled hours (p < 0.05), 3.5 fewer minutes spent in the In-Basket per provider per day (p < 0.05), but 13.7 more seconds spent per completed message per provider (p = 0.017), likely attributable to increased message complexity. Sixty-four percent of providers reported no burnout symptoms in a postintervention survey, 56% agreed that the AIM project reduced their burnout, and approximately 70% of providers agreed that the AIM project was acceptable and appropriate for their clinic.
Conclusion The AIM project demonstrates team-based nurse In-Basket triage is possible to implement across multiple primary care sites, is an acceptable intervention for providers, can reduce provider workload burden and self-reported provider burnout.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0044-1789575

23/10/2024

Optimizing Decision Support Alerts to Reduce Telemetry Duration: A Multicenter Evaluation

Niloofar Latifi, Trent Johnson, Amy M. Knight, Laura Prichett, Bahareh Modanloo, Trushar Dungarani, Sammy Zakaria, Amit Pahwa

Background Telemetry monitoring is crucial for high-risk patients but excessive use beyond practice standards increases costs. Prior studies have shown that electronic health record (EHR) alerts reduce low-value telemetry monitoring. However, specific components of these alerts that contribute to effectiveness are unknown.
Objectives We aimed to revise previously implemented EHR Best Practice Advisories (BPAs) to optimize their effectiveness in reducing telemetry duration. The secondary objective was to assess the impact on clinicians' alert burden.
Methods A multicenter retrospective study was conducted at Johns Hopkins Hospital (JHH), Johns Hopkins Bayview Medical Center (JHBMC), and Howard County General Hospital (HCGH). An EHR alert in the form of a BPA was previously implemented at JHH/JHBMC, firing at 24, 48, or 72 hours based on order indication. HCGH used an alert firing every 24 hours. A revised BPA was implemented at all hospitals optimizing the prior JHH/JHBMC alert by including patient-specific telemetry indications, restricting alerts to daytime hours (8:00 a.m.–6:00 p.m.), and embedding the discontinuation order within the BPA alert. A retrospective analysis from October 2018 to December 2021 was performed. The primary outcome was telemetry duration. The secondary outcome was the mean monthly BPA alerts per patient-day.
Results Compared with the original BPA, the revised BPA reduced telemetry duration by a mean of 6.7 hours (95% CI: 5.2–9.1 hours, p < 0.001) at JHH/JHBMC, with a minimal increase of 0.06 mean monthly BPA alerts per patient-day (p < 0.001). The BPA acceptance rate increased from 7.8 to 31.3% postintervention at JHH/JHBMC (p < 0.0001). At HCGH, the intervention led to a mean monthly reduction of 20.2 hours in telemetry duration per hospitalization (95% CI: 19.1–22.8 hours, p < 0.0001).
Conclusion Optimizing EHR BPAs reduces unnecessary telemetry duration without substantially increasing clinician alert burden. This study highlights the importance of tailoring EHR alerts to enhance effectiveness and promote value-based care.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0044-1789574

16/10/2024

Health Information Technology Documentation and Referrals for Intimate Partner Violence and Sexual Assault

Joshua E. Richardson, Jaclyn Houston-Kolnik, Stefany Ramos, Devin Oxner, Paige Presler-Jur

Background Hospital settings provide a unique opportunity to screen for intimate partner violence (IPV) and sexual assault (SA) yet often lack health information technology (IT) solutions for generating reliable and valid medicolegal documentation via forensic reports.
Objectives The objective of the project was to evaluate a pilot, technology “tool” for documenting cases of IPV and SA that could support forensic nurse examiners and related stakeholders in generating high-quality documentation and coordinating victim support services.
Methods The tool was a digital health intervention implemented for use among forensic nurse examiners, law enforcement, victim support organizations, and more within four counties of California. We conducted a mixed-methods pilot study that captured data around the adoption, use, and impact of having access to the newly implemented tool.
Results The tool successfully went live in all four pilot counties at different time points with different proportions of use by county and form type: exams, referrals, addenda, risk assessments, and other. Participants were motivated to use the tool out of a perceived need for data handling functionalities that went beyond traditional manual (paper) means. Key functionalities included body mapping, data quality controls within validated forms, attaching addenda to already existing case reports, and the means to distribute data to external recipients. Further study and development are needed on functions to incorporate into body maps and forms and understanding the information needs of law enforcement and victim support organizations.
Conclusion Our evaluation demonstrated the feasibility and acceptability of a health IT tool to support forensic nurse documentation of IPV and SA and direct information to multiple legal and support-related stakeholders. Areas of future development include integrating IPV- and SA-related data standards for digitized forms, enhancements to the body mapping feature, and understanding the needs of those who receive digital data from forensic nurse examiners within the tool.

Thieme E-Books & E-Journals

16/10/2024

Increasing Generative Artificial Intelligence Competency among Students Enrolled in Doctoral Nursing Research Coursework

Meghan Reading Turchioe, Sergey Kisselev, Liesbet Van Bulck, Suzanne Bakken

Background Generative artificial intelligence (AI) tools may soon be integrated into health care practice and research. Nurses in leadership roles, many of whom are doctorally prepared, will need to determine whether and how to integrate them in a safe and useful way.
Objective This study aimed to develop and evaluate a brief intervention to increase PhD nursing students' knowledge of appropriate applications for using generative AI tools in health care.
Methods We created didactic lectures and laboratory-based activities to introduce generative AI to students enrolled in a nursing PhD data science and visualization course. Students were provided with a subscription to Chat Generative Pretrained Transformer (ChatGPT) 4.0, a general-purpose generative AI tool, for use in and outside the class. During the didactic portion, we described generative AI and its current and potential future applications in health care, including examples of appropriate and inappropriate applications. In the laboratory sessions, students were given three tasks representing different use cases of generative AI in health care practice and research (clinical decision support, patient decision support, and scientific communication) and asked to engage with ChatGPT on each. Students (n = 10) independently wrote a brief reflection for each task evaluating safety (accuracy, hallucinations) and usability (ease of use, usefulness, and intention to use in the future). Reflections were analyzed using directed content analysis.
Results Students were able to identify the strengths and limitations of ChatGPT in completing all three tasks and developed opinions on whether they would feel comfortable using ChatGPT for similar tasks in the future. All of them reported increasing their self-rated competency in generative AI by one to two points on a five-point rating scale.
Conclusion This brief educational intervention supported doctoral nursing students in understanding the appropriate uses of ChatGPT, which may support their ability to appraise and use these tools in their future work.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/a-2373-3151

16/10/2024

What Do We Mean by Sharing of Patient Data? DaSH: A Data Sharing Hierarchy of Privacy and Ethical Challenges

Richard Schreiber , Ross Koppel , Bonnie Kaplan

Background Clinical data sharing is common and necessary for patient care, research, public health, and innovation. However, the term “data sharing” is often ambiguous in its many facets and complexities—each of which involves ethical, legal, and social issues. To our knowledge, there is no extant hierarchy of data sharing that assesses these issues.
Objective This study aimed to develop a hierarchy explicating the risks and ethical complexities of data sharing with a particular focus on patient data privacy.
Methods We surveyed the available peer-reviewed and gray literature and with our combined extensive experience in bioethics and medical informatics, created this hierarchy.
Results We present six ways on how data are shared and provide a tiered Data Sharing Hierarchy (DaSH) of risks, showing increasing threats to patients' privacy, clinicians, and organizations as one progresses up the hierarchy from data sharing for direct patient care, public health and safety, scientific research, commercial purposes, complex combinations of the preceding efforts, and among networked third parties. We offer recommendations to enhance the benefits of data sharing while mitigating risks and protecting patients' interests by improving consenting; developing better policies and procedures; clarifying, simplifying, and updating regulations to include all health-related data regardless of source; expanding the scope of bioethics for information technology; and increasing ongoing monitoring and research.
Conclusion Data sharing, while essential for patient care, is increasingly complex, opaque, and perhaps perilous for patients, clinicians, and health care institutions. Risks increase with advances in technology and with more encompassing patient data from wearables and artificial intelligence database mining. Data sharing places responsibilities on all parties: patients, clinicians, researchers, educators, risk managers, attorneys, informaticists, bioethicists, institutions, and policymakers.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/a-2373-3291

09/10/2024

A Standard Approach to Project-Based Learning in a Clinical Informatics

Michael G. Leu, Angad P. Singh, Christopher W. Lewis, B. Jane Fellner, Theresa B. Kim, Yu-Hsiang Lin, Paul R. Sutton, Andrew A. White, Peter Tarczy-Hornoch

Background The Accreditation Council for Graduate Medical Education suggests that Clinical Informatics (CI) fellowship programs foster broad skills, which include collaboration and project management. However, they do not dictate how to best accomplish these learning objectives.
Objectives This study aimed to describe a standard approach to project-based learning for CI, to share its implementation, and to discuss lessons learned.
Methods We created a standard approach to project-based learning based on concepts from adult learning theory, the project life cycle framework, the Toyota Production System, and Improvement Science.
Results With this standard approach in place, we learned how best to support fellows in its use. In addition to this approach to supporting needs assessment, risk/change management, implementation, and evaluation/improvement skills, we found the need to develop fellow skills in collaboration, leadership, and time management/managing up. Supported by project-based learning using this standard approach, and with targeted project selection to meet topic-based learning objectives, fellows reached the ability to practice independently in 15 to 21 months.
Discussion Fellows are uniquely positioned to ensure the success of projects due to their increased availability and protected time compared with attendings. They are readily available for project teams to draw upon their expertise with clinical workflows and understanding of technological solutions. Project-based learning addressing organizational priorities complements fellow project management coursework and improves fellows' ability to function successfully in large, complex, and dynamic organizations. Exposing fellows to contemporary problems, then addressing them through projects, provides fellows with up-to-date applied informatics knowledge.
Conclusion Project-based learning can ensure that many general CI learning objectives are supported inherently. It reinforces project management teachings, while providing fellows with a marketable project portfolio to aid with future job applications. Having projects tightly aligned with organizational priorities supports ongoing investment in fellowship programs.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0044-1788980

09/10/2024

Shared Access to Adults' Patient Portals: A Secret Shopper Exercise

Deborah Wachenheim, Isabel Hurwitz, Vadim Dukhanin, Jennifer L. Wolff, Catherine M. DesRoches

Background Millions of Americans manage their health care with the help of a trusted individual. Shared access to a patient's online patient portal is one tool that can assist their care partner(s) in gaining access to the patient's health information and allow for easy exchange with the patient's care team. Shared access provides care partners with a validated and secure method for accessing the patient's portal account using their own login credentials. Shared access provides extra privacy protection and control to the patient, who designates which individuals can view their record. It also reduces confusion for the care team when interacting with the care partner via the portal. Shared access is underutilized among adult patients' care partners.
Objectives Investigate the process of granting or receiving shared access at multiple health care organizations in the United States to learn about barriers and facilitators experienced by patients and care partners.
Methods The Shared Access Learning Collaborative undertook a “Secret Shopper” exercise. Participants attempted to give or gain shared access to another adult's portal account. After each attempt they completed a 14-question survey with a mix of open- and closed-ended questions.
Results Eighteen participants attempted to grant or receive shared access a total of 24 times. Fifteen attempts were successful. Barriers to success included requiring paper forms with signatures, lack of knowledgeable staff, lack of access to technical support, and difficult-to-navigate technology. Facilitators included easy-to-navigate online processes and accessible technical help. Participants who were successful in gaining shared access reported feeling more informed and able to engage in shared decision-making.
Conclusion The outcomes of our secret shopper exercise underscore the importance of collaboration aimed at learning from diverse encounters and disseminating the best practices. This is essential to address technical, informational, and organizational obstacles that may impede the widespread and accessible adoption of shared access.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/a-2370-2220

09/10/2024

A Medical Student-Led Multipronged Initiative to Close the Digital Divide in Outpatient Primary Monroe Carell Jr. Children's Hospital at Vanderbilt

Yilan Jiangliu, Hannah T. Kim, Michelle Lazar, Eileen Liu, Saaz Mantri, Edwin Qiu, Megan Berube, Himani Sood, Anika S. Walia, Breanne E. Biondi, Andres M. Mesias, Rebecca Mishuris, Pablo Buitron de la Vega

Background The coronavirus disease 2019 pandemic accelerated the use of telehealth. However, this also exacerbated health care disparities for vulnerable populations.
Objectives This study aimed to explore the feasibility and effectiveness of a medical student-led initiative to identify and address gaps in patient access to digital health resources in adult primary care clinics at an academic safety-net hospital.
Methods Medical students used an online HIPAA-compliant resource directory to screen for digital needs, connect patients with resources, and track outcome metrics. Through a series of Plan-Do-Study-Act (PDSA) cycles, the program grew to offer services such as information and registration for subsidized internet and phone services via the Affordable Connectivity Program (ACP) and Lifeline, assistance setting up and utilizing MyChart (an online patient portal for access to electronic health records), orientation to telehealth applications, and connection to community-based digital literacy training.
Results Between November 2021 and March 2023, the program received 608 assistance requests. The most successful intervention was MyChart help, resulting in 83% of those seeking assistance successfully signing up for MyChart accounts and 79% feeling comfortable navigating the portal. However, subsidized internet support, digital literacy training, and telehealth orientation had less favorable outcomes. The PDSA cycles highlighted numerous challenges such as inadequate patient outreach, time-consuming training, limited in-person support, and unequal language assistance. To overcome these barriers, the program evolved to utilize clinic space for outreach, increase flier distribution, standardize training, and enhance integration of multilingual resources.
Conclusion This study is, to the best of our knowledge, the first time a medical student-led initiative addresses the digital divide with a multipronged approach. We outline a system that can be implemented in other outpatient settings to increase patients' digital literacy and promote health equity, while also engaging students in important aspects of nonclinical patient care.

https://www.thieme-connect.de/products/ejournals/abstract/10.1055/a-2370-2298