A Study of the Contextual Factors Influencing Emergency Department Clinician’s Diagnostic Test Ordering Decision Making

Australia’s total number of pathology tests and imaging services covered by the Medicare Benefits Schedule has increased by over 50% in the last decade. Given that 20-25% of the common pathology tests were considered inappropriate nationwide, an increasing burden is being placed on the whole healthcare system by unnecessary diagnostic tests (UDTs). The objective of this exploratory study is to identify the contextual factors that could influence a clinician’s diagnostic test ordering decision-making (DTODM) in an Emergency Department (ED). Semi-structured interviews were conducted with 19 ED clinicians. Four factors have been identified, including organizational context, patient/family preferences, resource availability, and influences by senior clinicians. The study offers new lenses in clinical reasoning for emergency medicine teaching and training through the eyes of ED clinicians. It also outlines an opportunity to introduce novel clinical decision support to assist with clinicians’ test ordering without causing alert fatigue or bringing stress

Emergency Department Clinicians’ Attitudes Toward Opioid Use Disorder and Emergency Department-initiated Buprenorphine Treatment: A Mixed-Methods Study

Introduction: Emergency department (ED) visits related to opioid use disorder (OUD) have increased nearly twofold over the last decade. Treatment with buprenorphine has been demonstrated to decrease opioid-related overdose deaths. In this study, we aimed to better understand ED clinicians’ attitudes toward the initiation of buprenorphine treatment in the ED.Methods: We performed a mixed-methods study consisting of a survey of 174 ED clinicians (attending physicians, residents, and physician assistants) and semi-structured interviews with 17 attending emergency physicians at a tertiary-care academic hospital.Results: A total of 93 ED clinicians (53% of those contacted) completed the survey. While 80% of respondents agreed that buprenorphine should be administered in the ED for patients requesting treatment, only 44% felt that they were prepared to discuss medication for addiction treatment. Compared to clinicians with fewer than five years of practice, those with greater experience were less likely to approve of ED-initiated buprenorphine. In our qualitative analysis, physicians had differing perspectives on the role that the ED should play in treating OUD. Most physicians felt that a buprenorphine-based intervention in the ED would be feasible with institutional support, including training opportunities, protocol support within the electronic health record, counseling and support staff, and a robust referral system for outpatient follow-up.Conclusion: ED clinicians’ perception of buprenorphine varied by years of practice and training level. Most ED clinicians did not feel prepared to initiate buprenorphine in the ED. Qualitative interviews identified several addressable barriers to ED-initiated buprenorphine

Optimal urine culture diagnostic stewardship practice- Results from an expert modified-Delphi procedure

BACKGROUND: Urine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship. METHODS: A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed. RESULTS: One hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions. CONCLUSIONS: These 18 guidance statements can optimize use of urine cultures for better patient outcomes

Achieving Efficiency: Lessons From Four Top-Performing Hospitals

Synthesizes lessons from case studies of how four hospitals achieved greater efficiency, including pursuing quality and access, customizing technology, emphasizing communications, standardizing processes, and integrating care, systems, and providers

The organizational implications of medical imaging in the context of Malaysian hospitals

This research investigated the implementation and use of medical imaging in the context of Malaysian hospitals. In this report medical imaging refers to PACS, RIS/HIS and imaging modalities which are linked through a computer network. The study examined how the internal context of a hospital and its external context together influenced the implementation of medical imaging, and how this in turn shaped organizational roles and relationships within the hospital itself. It further investigated how the implementation of the technology in one hospital affected its implementation in another hospital. The research used systems theory as the theoretical framework for the study. Methodologically, the study used a case-based approach and multiple methods to obtain data. The case studies included two hospital-based radiology departments in Malaysia. The outcomes of the research suggest that the implementation of medical imaging in community hospitals is shaped by the external context particularly the role played by the Ministry of Health. Furthermore, influences from both the internal and external contexts have a substantial impact on the process of implementing medical imaging and the extent of the benefits that the organization can gain. In the context of roles and social relationships, the findings revealed that the routine use of medical imaging has substantially affected radiographers’ roles, and the social relationships between non clinical personnel and clinicians. This study found no change in the relationship between radiographers and radiologists. Finally, the approaches to implementation taken in the hospitals studied were found to influence those taken by other hospitals. Overall, this study makes three important contributions. Firstly, it extends Barley’s (1986, 1990) research by explicitly demonstrating that the organization’s internal and external contexts together shape the implementation and use of technology, that the processes of implementing and using technology impact upon roles, relationships and networks and that a role-based approach alone is inadequate to examine the outcomes of deploying an advanced technology. Secondly, this study contends that scalability of technology in the context of developing countries is not necessarily linear. Finally, this study offers practical contributions that can benefit healthcare organizations in Malaysia

A conceptual framework and protocol for defining clinical decision support objectives applicable to medical specialties.

BackgroundThe U.S. Centers for Medicare and Medicaid Services established the Electronic Health Record (EHR) Incentive Program in 2009 to stimulate the adoption of EHRs. One component of the program requires eligible providers to implement clinical decision support (CDS) interventions that can improve performance on one or more quality measures pre-selected for each specialty. Because the unique decision-making challenges and existing HIT capabilities vary widely across specialties, the development of meaningful objectives for CDS within such programs must be supported by deliberative analysis.DesignWe developed a conceptual framework and protocol that combines evidence review with expert opinion to elicit clinically meaningful objectives for CDS directly from specialists. The framework links objectives for CDS to specialty-specific performance gaps while ensuring that a workable set of CDS opportunities are available to providers to address each performance gap. Performance gaps may include those with well-established quality measures but also priorities identified by specialists based on their clinical experience. Moreover, objectives are not constrained to performance gaps with existing CDS technologies, but rather may include those for which CDS tools might reasonably be expected to be developed in the near term, for example, by the beginning of Stage 3 of the EHR Incentive program. The protocol uses a modified Delphi expert panel process to elicit and prioritize CDS meaningful use objectives. Experts first rate the importance of performance gaps, beginning with a candidate list generated through an environmental scan and supplemented through nominations by panelists. For the highest priority performance gaps, panelists then rate the extent to which existing or future CDS interventions, characterized jointly as "CDS opportunities," might impact each performance gap and the extent to which each CDS opportunity is compatible with specialists' clinical workflows. The protocol was tested by expert panels representing four clinical specialties: oncology, orthopedic surgery, interventional cardiology, and pediatrics

Master of Science

thesisAnnually, 46 million patients, or 37% of patients seen in the emergency department (ED), receive laboratory testing in the U.S.; thus, making efficient lab order and result management critical to improving ED throughput, clinical efficacy, and safety. In order to manage labs and other processes, electronic emergency department tracking systems (EDTS) or electronic whiteboards have evolved features that support clinical, operational, and administrative needs. EDTSs have often augmented manual data entry with interfaces and/or integration with other systems such as registration, laboratory, radiology, and clinical information systems (CIS). One such integration evaluated in this study, EDTS/CIS context sharing, was added to automatically pass all necessary user, patient, and application parameters between the two systems in order to open the CIS lab module for a selected patient when the user is notified in the EDTS that laboratory test results for that patient are available for review. Therefore, context sharing eliminated multiple user steps needed to log-on, search, select, and navigate to the lab viewing module in order to view a patient's lab results. This study evaluates the effects of adding EDTS/CIS context sharing to an EDTS with lab notifications on ED process times. These effects were measured utilizing a pre- and post-intervention design for all ED encounters where specific common labs were resulted. A method of analyzing CIS audit logs in combination with EDTS and laboratory information system timestamps was implemented to measure patient management processes for quality improvement. After adding context sharing to lab notification features, the median interval between the availability of lab results and review of those results by the ordering provider decreased from 22.7 min., by 25% or 5.7 min. (p-value < 0.001), to 17.0 min. However, median time from resulting of labs to patient discharge were essentially unchanged, decreasing from 106.6 min. to 105.0 min. (p-value = 0.080). The proportion of lab results reviewed by physicians in the CIS integrated with the EDTS increased from 66% to 86% after the intervention (p-value < 0.001). EDTS/CIS context sharing and passive lab notification features improved the timeliness and completion of lab result review in the CIS and increased system adoption in this setting. However, reductions in the time intervals to review of lab results in the CIS did not result in an operationally or statistically significant improvement in time to discharge after the availability of results

Connected: Using a Novel In-House Communication System to Efficiently Deliver Imaging Results

Introduction: The primary objective was to investigate the effectiveness of a fully staffed electronic communication system (1Connect) in delivering timely critical imaging results and incidental findings. The secondary objective was to evaluate the financial impact of this system on a radiology practice. Methods: From January 2014 through June 2016, the 1Connect database was retrospectively reviewed and sorted by category of submission type: Critical (1-hour communication time), STAT (2 hours), or Unexpected finding (3 business days). The percent of successful communications completed within the appropriate time frame was calculated for each priority category and used as a measure of the system’s efficiency and effectiveness. The financial impact of 1Connect was then estimated using an average radiologist salary in Portland, Maine, combined with the radiologist time saved using this system. Results: More than 96% of time-sensitive results (critical and STAT categories) were communicated within their predetermined time limits with the 1Connect system. Using this system, the estimated value of radiologist time saved by 1Connect staff was approximately $50 997 per year. Conclusions: Spectrum Radiology’s 1Connect system presents a novel approach that supports timely and cost-effective communication of imaging findings to treating providers. While patient outcomes and safety were not evaluated in this study, patient care is likely enhanced when critical findings are promptly communicated to referring providers