Missing Pieces in Health Services Cost Analysis: Consensus on Modeling, Magnitude, and Micro-Costing

Cost and cost savings have become an important focus for health policy administrators. However, there are missing pieces in our approach to cost analysis; there is no consensus on multivariable methods, no indicators of minimally acceptable values, and no specification of process costing. In this dissertation, I propose to fill the gaps in the literature by 1) identifying which methods are appropriate for large claims data, 2) examine existing methods to establish minimally important difference (MID) in health outcomes to identify MID in costs, and 3) determine differences in sick visit clinic costs using a modified micro-costing method. Most models that were compared to the generalized linear models Gamma distribution with log link found it to be the superior model in both simulated data and real administrative data. We recommend that in cases where acceptable anchors are not available to establish an MID, both the Delphi and the distribution-method of MID for costs be explored for convergence. Our micro-costing approach is feasible to use under virtual working conditions; requires minimal provider time; and generates detailed cost estimates that have “face validity” with providers and are relevant for economic evaluation

Utilization of automated location tracking for clinical workflow analytics and visualization

abstract: The analysis of clinical workflow offers many challenges to clinical stakeholders and researchers, especially in environments characterized by dynamic and concurrent processes. Workflow analysis in such environments is essential for monitoring performance and finding bottlenecks and sources of error. Clinical workflow analysis has been enhanced with the inclusion of modern technologies. One such intervention is automated location tracking which is a system that detects the movement of clinicians and equipment. Utilizing the data produced from automated location tracking technologies can lead to the development of novel workflow analytics that can be used to complement more traditional approaches such as ethnography and grounded-theory based qualitative methods. The goals of this research are to: (i) develop a series of analytic techniques to derive deeper workflow-related insight in an emergency department setting, (ii) overlay data from disparate sources (quantitative and qualitative) to develop strategies that facilitate workflow redesign, and (iii) incorporate visual analytics methods to improve the targeted visual feedback received by providers based on the findings. The overarching purpose is to create a framework to demonstrate the utility of automated location tracking data used in conjunction with clinical data like EHR logs and its vital role in the future of clinical workflow analysis/analytics. This document is categorized based on two primary aims of the research. The first aim deals with the use of automated location tracking data to develop a novel methodological/exploratory framework for clinical workflow. The second aim is to overlay the quantitative data generated from the previous aim on data from qualitative observation and shadowing studies (mixed methods) to develop a deeper view of clinical workflow that can be used to facilitate workflow redesign. The final sections of the document speculate on the direction of this work where the potential of this research in the creation of fully integrated clinical environments i.e. environments with state-of-the-art location tracking and other data collection mechanisms, is discussed. The main purpose of this research is to demonstrate ways by which clinical processes can be continuously monitored allowing for proactive adaptations in the face of technological and process changes to minimize any negative impact on the quality of patient care and provider satisfaction.Dissertation/ThesisDoctoral Dissertation Biomedical Informatics 201

Modeling the workflow of one primary care physician-nurse team.

Primary care has been identified as a vital part of the healthcare system in the U.S., and one that operates in a challenging, unique environment. Primary care sees a wide variety of patients and is undergoing a series of major transformations simultaneously. As a result, primary care would greatly benefit from a systemic approach to the analysis of its workflows. Discrete-event simulation has been identified as a good tool to evaluate complex healthcare systems. The existing primary care DES models focus on the physician. Also, those models are limited in (a) their usefulness to produce generic models that can easily and quickly be customized and (b) the analysis of the specific tasks performed to treat a patient. Hence, a research idea was developed to address these limitations, which led to a progressive multi-part study developing the necessary components to model a primary clinic. The study was constructed to allow each progressive study to build on the previous. The first part of the study developed a new approach to address those limitations: modeling a primary care clinic from the viewpoint that the physician is the entity that moves through the system. This approach was implemented based on observational data and a standardized primary care physician task list using ARENA© simulation software. The completed model is evidence-based, with the simulation producing predictions and analysis associated with a given patient visit that has not happened by mimicking reality. The benefits of this type of flexible model are that it allows for analysis of any type of “cost” that can be quantified, and it can then be utilized for predicting and potentially subsequently reducing procedural errors and variation in order to increase operational efficiency. The second part of the study was to develop a standardized primary care nurse task list, which is needed given the current transformation of primary care from a doctor-based model to a team-based model. A comprehensive, validated list of tasks occurring during clinic visits was complied from a secondary data analysis. For this, primary care clinics in Wisconsin were selected from a pre-existing study based on 100% participation of the physician-nurse teams. The final task list had 18 major tasks and 174 second-level subtasks, with 103 additional third-level tasks. This task list, combined with the primary care physician task list, provides a tool set that facilitates clinics’ analysis of the workflow associated with a complete patient encounter. Finally, the third part of the study used observational data, the standardized primary care nurse task list, and a similar modeling methodology to the first part to develop a simulation model of the primary care nurse. The model was implemented using ARENA© simulation software. This model is flexible, resulting in an easily-customizable model, and robust in that it allows the analysis of any type of “cost” that can be quantified, such as time, physical or mental resources, money, et cetera. This can potentially be used to predict, and reduce, procedural errors and variation in response to changes to the workflows or environment; hence, the operational efficiency and medical accuracy can be more accurately evaluated

Scott & White Healthcare: Opening Up and Embracing Change to Improve Performance

Offers a case study of a multispeciality system with the attributes of an ideal healthcare delivery system as defined by the Fund. Describes a culture of continuous improvement, collaboration and peer accountability, and a comprehensive approach to care

Increasing efficacy of primary care-based counseling for diabetes prevention: Rationale and design of the ADAPT (Avoiding Diabetes Thru Action Plan Targeting) trial

<p>Abstract</p> <p>Background</p> <p>Studies have shown that lifestyle behavior changes are most effective to prevent onset of diabetes in high-risk patients. Primary care providers are charged with encouraging behavior change among their patients at risk for diabetes, yet the practice environment and training in primary care often do not support effective provider counseling. The goal of this study is to develop an electronic health record-embedded tool to facilitate shared patient-provider goal setting to promote behavioral change and prevent diabetes.</p> <p>Methods</p> <p>The ADAPT (Avoiding Diabetes Thru Action Plan Targeting) trial leverages an innovative system that integrates evidence-based interventions for behavioral change with already-existing technology to enhance primary care providers' effectiveness to counsel about lifestyle behavior changes. Using principles of behavior change theory, the multidisciplinary design team utilized in-depth interviews and <it>in vivo </it>usability testing to produce a prototype diabetes prevention counseling system embedded in the electronic health record.</p> <p>Results</p> <p>The core element of the tool is a streamlined, shared goal-setting module within the electronic health record system. The team then conducted a series of innovative, "near-live" usability testing simulations to refine the tool and enhance workflow integration. The system also incorporates a pre-encounter survey to elicit patients' behavior-change goals to help tailor patient-provider goal setting during the clinical encounter and to encourage shared decision making. Lastly, the patients interact with a website that collects their longitudinal behavior data and allows them to visualize their progress over time and compare their progress with other study members. The finalized ADAPT system is now being piloted in a small randomized control trial of providers using the system with prediabetes patients over a six-month period.</p> <p>Conclusions</p> <p>The ADAPT system combines the influential powers of shared goal setting and feedback, tailoring, modeling, contracting, reminders, and social comparisons to integrate evidence-based behavior-change principles into the electronic health record to maximize provider counseling efficacy during routine primary care clinical encounters. If successful, the ADAPT system may represent an adaptable and scalable technology-enabled behavior-change tool for all primary care providers.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov Identifier <a href="http://www.clinicaltrials.gov/ct2/show/NCT01473654">NCT01473654</a></p

Usability analysis of contending electronic health record systems

In this paper, we report measured usability of two leading EHR systems during procurement. A total of 18 users participated in paired-usability testing of three scenarios: ordering and managing medications by an outpatient physician, medicine administration by an inpatient nurse and scheduling of appointments by nursing staff. Data for audio, screen capture, satisfaction rating, task success and errors made was collected during testing. We found a clear difference between the systems for percentage of successfully completed tasks, two different satisfaction measures and perceived learnability when looking at the results over all scenarios. We conclude that usability should be evaluated during procurement and the difference in usability between systems could be revealed even with fewer measures than were used in our study. © 2019 American Psychological Association Inc. All rights reserved.Peer reviewe

Electronic Health Record Optimization for Cardiac Care

Electronic health record (EHR) systems have been studied for over 30 years, and despite the benefits of information technology in other knowledge domains, progress has been slow in healthcare. A growing body of evidence suggests that dissatisfaction with EHR systems was not simply due to resistance to adoption of new technology but also due to real concerns about the adverse impact of EHRs on the delivery of patient care. Solutions for EHR improvement require an approach that combines an understanding of technology adoption with the complexity of the social and technical elements of the US healthcare system. Several studies are presented to clarify and propose a new framework to study EHR-provider interaction. Four focus areas were defined - workflow, communication, medical decision-making and patient care. Using Human Computer Interaction best practices, an EHR usability framework was designed to include a realistic clinical scenario, a cognitive walkthrough, a standardized simulated patient actor, and a portable usability lab. Cardiologists, fellows and nurse practitioners were invited to participate in a simulation to use their institution’s EHR system for a routine cardiac visit. Using a mixed methods approach, differences in satisfaction and effectiveness were identified. Cardiologists were dissatisfied with EHR functionality, and were critical of the potential impact of the communication of incorrect information, while displaying the highest level of success in completing the tasks. Fellows were slightly less dissatisfied with their EHR interaction, and demonstrated a preference for tools to improve workflow and support decision-making, and showed less success in completing the tasks in the scenario. Nurse practitioners were also dissatisfied with their EHR interaction, and cited poor organization of data, yet demonstrated more success than fellows in successful completion of tasks. Study results indicate that requirements for EHR functionality differ by type of provider. Cardiologists, cardiology fellows, and nurse practitioners required different levels of granularity of patient data for use in medical decision-making, defined different targets for communication, sought different solutions to workflow which included distribution of data input, and requested technical solutions to ensure valid and relevant patient data. These findings provide a foundation for future work to optimize EHR functionality

Every Drop Counts: Quantifying Blood Loss Can Lead to Early Detection and Intervention for Postpartum Hemorrhage

Abstract A visual estimation has been the standard measurement for blood loss post vaginal or cesarean section delivery. Research has shown that visual estimation also known as estimated blood loss has led to an underestimation of total blood loss volume. This results in over 100,000 women per year in the United States that experience an adverse effect due to delayed recognition and treatment for postpartum hemorrhage. By quantifying blood loss, the volume is measured by a one to one ratio; one-gram weight is equal to one-milliliter blood volume. To promote the evidence-based practice of quantifying blood loss, a quality improvement project was designed and implemented in a labor and delivery department of a suburban, community-based hospital on the city limits of Philadelphia, Pennsylvania. Data were collected via a retrospective record review before and following the implementation of quantifying blood loss measurement during the recovery period of all deliveries. Results: Clinical significance was noted utilizing quantified blood loss during the recovery period following vaginal and cesarean section deliveries. The rate of postpartum hemorrhage did decrease from 7.6% pre-intervention to 5.6% post-intervention, although this result was not statistically significant. Keywords: Postpartum hemorrhage, postpartum blood loss, maternal mortality, maternal morbidity, estimated blood loss, quantified blood los

Emergency physician documentation quality and cognitive load : comparison of paper charts to electronic physician documentation

Indiana University-Purdue University Indianapolis (IUPUI)Reducing medical error remains in the forefront of healthcare reform. The use of health information technology, specifically the electronic health record (EHR) is one attempt to improve patient safety. The implementation of the EHR in the Emergency Department changes physician workflow, which can have negative, unintended consequences for patient safety. Inaccuracies in clinical documentation can contribute, for example, to medical error during transitions of care. In this quasi-experimental comparison study, we sought to determine whether there is a difference in document quality, error rate, error type, cognitive load and time when Emergency Medicine (EM) residents use paper charts versus the EHR to complete physician documentation of clinical encounters. Simulated patient encounters provided a unique and innovative environment to evaluate EM physician documentation. Analysis focused on examining documentation quality and real-time observation of the simulated encounter. Results demonstrate no change in document quality, no change in cognitive load, and no change in error rate between electronic and paper charts. There was a 46% increase in the time required to complete the charting task when using the EHR. Physician workflow changes from partial documentation during the patient encounter with paper charts to complete documentation after the encounter with electronic charts. Documentation quality overall was poor with an average of 36% of required elements missing which did not improve during residency training. The extra time required for the charting task using the EHR potentially increases patient waiting times as well as clinician dissatisfaction and burnout, yet it has little impact on the quality of physician documentation. Better strategies and support for documentation are needed as providers adopt and use EHR systems to change the practice of medicine

Evaluation of Cardiovascular Risk Compliance for Primary Prevention: A Quality Improvement Project

The American College of Cardiology and American Heart Association clinical practice guidelines recommend a cardiovascular risk assessment every 4–6 years in ages 40–75 to prevent cardiovascular disease. This DNP project aimed to improve awareness, compliance with cardiac risk assessments, and stratification of high and low-risk patients. This quality improvement project utilized the Johns Hopkins nursing evidence-based model to create the inquiry question and foundational plan for implementing the clinical practice guideline, calculating the cardiac risk score, and creating a clinical workflow process. A retrospective chart audit was guided by the Plan-Do-Study-Act (PDSA) method to collect pre- and postintervention data on compliance with the clinical practice guideline, and a pre-/posttest survey to measure the effect of an educational intervention on healthcare provider behavior. In evaluating the data, the PDSA allowed for revisions in the implementation plan. The goals of the DNP project were to reveal a 10% increase in compliance with the completion of cardiac risk assessments with the use of the workflow process and an increase in the data analyzed from the pretest and posttest to show an increase in knowledge of cardiovascular disease guidelines. The project study question was answered with 2 (4.4%) in compliance with completing the cardiac risk assessment postintervention. Low risk, less than 5% chance of having a cardiovascular event in the next 10 years, was predominantly N = 45 found among the participants with no cardiac risk assessment completed 43 (95.6%), the next highest level, intermediate, 12 (100%), and 2 (100%) were borderline. The difference between pre- and posttest survey results revealed with respect to the healthcare provider belief in question 7 (z = -2.000, p = .046) was statistically significant (p \u3c .05). An inverse relationship with the ASCVD level, the risk is lower as HDL increases. The results of this DNP project suggest an evidence-based educational intervention can improve knowledge of screening cardiac risk assessment guidelines, compliance with the clinical practice guideline, and workflow process for a sustainable practice change leading to positive patient outcomes