Evaluating a Modular Decision Support Application For Colorectal Cancer Screening

BACKGROUND: There is a need for health information technology evaluation that goes beyond randomized controlled trials to include consideration of usability, cognition, feedback from representative users, and impact on efficiency, data quality, and clinical workflow. This article presents an evaluation illustrating one approach to this need using the Decision-Centered Design framework. OBJECTIVE: To evaluate, through a Decision-Centered Design framework, the ability of the Screening and Surveillance App to support primary care clinicians in tracking and managing colorectal cancer testing. METHODS: We leveraged two evaluation formats, online and in-person, to obtain feedback from a range primary care clinicians and obtain comparative data. Both the online and in-person evaluations used mock patient data to simulate challenging patient scenarios. Primary care clinicians responded to a series of colorectal cancer-related questions about each patient and made recommendations for screening. We collected data on performance, perceived workload, and usability. Key elements of Decision-Centered Design include evaluation in the context of realistic, challenging scenarios and measures designed to explore impact on cognitive performance. RESULTS: Comparison of means revealed increases in accuracy, efficiency, and usability and decreases in perceived mental effort and workload when using the Screening and Surveillance App. CONCLUSION: The results speak to the benefits of using the Decision-Centered Design approach in the analysis, design, and evaluation of Health Information Technology. Furthermore, the Screening and Surveillance App shows promise for filling decision support gaps in current electronic health records

Doctor of Philosophy

dissertationInadequate care coordination has been identified as a significant problem in patient care, resulting in diminished satisfaction, increased cost, and reduced quality of care. Comprising an estimated 15.6% (approximately 11 million) of the pediatric population, children and youth with special health care needs (CYSHCN) are "those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally". Caring for CYSHCN is often highly complex, time-, effort-, and resource-intensive, due to complex healthcare conditions, comorbidities, and age of patients. Current electronic health record (EHR) and personal health record (PHR) systems do not adequately support the needs of care coordination. The reasons for this include lack of appropriate tools to support complex care coordination tasks, poor usability, and gaps in information essential for providing team-based patient care. The issues are further amplified while coordinating care for CYSHCN because their health records tend to be voluminous, involve a large care team, and are distributed over multiple systems typically with little to no interoperability. To develop tools that promote effective and efficient care coordination, designers must first understand what information is needed, who needs it, when they need it, and how it can be made available. Our first study focused on identifying and describing information needs and associated goals related to coordinating care for CYSHCN. We found that a critical information goal for care coordination is care networking, which includes building a patient's care team; knowing team member identities, roles, and contact information; and sharing pertinent information with the team to coordinate care. In our second study, we designed and developed two versions of a patient-, family-, and clinician-facing tool to support care networking. We then conducted a formative evaluation and compared the usability, usefulness, and efficiency of the two versions. To enable such tools to help with management of information critical to care coordination, information for care networking needs to be obtained from all information sources involved in the patient's care. In our third study, we identified and assessed prevalent and emerging national data standards to support electronic exchange and extraction of patient care team related data. The findings and innovations from this research are envisioned to help guide the design and development of next generation clinician- and patient-/family-facing applications to support care coordination of complex pediatric patients

Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study

© 2018, The Author(s). Abstract: To determine the validity of the Australian clinical prediction tool Criteria for Screening and Triaging to Appropriate aLternative care (CRISTAL) based on objective clinical criteria to accurately identify risk of death within 3 months of admission among older patients. Methods: Prospective study of ≥ 65 year-olds presenting at emergency departments in five Australian (Aus) and four Danish (DK) hospitals. Logistic regression analysis was used to model factors for death prediction; Sensitivity, specificity, area under the ROC curve and calibration with bootstrapping techniques were used to describe predictive accuracy. Results: 2493 patients, with median age 78–80 years (DK–Aus). The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% CI 7.7–8.6 vs. 5.8 95% CI 5.6–5.9) and Danish mean 7.1 (95% CI 6.6–7.5 vs. 5.5 95% CI 5.4–5.6). The model with Fried Frailty score was optimal for the Australian cohort but prediction with the Clinical Frailty Scale (CFS) was also good (AUROC 0.825 and 0.81, respectively). Values for the Danish cohort were AUROC 0.764 with Fried and 0.794 using CFS. The most significant independent predictors of short-term death in both cohorts were advanced malignancy, frailty, male gender and advanced age. CriSTAL’s accuracy was only modest for in-hospital death prediction in either setting. Conclusions: The modified CriSTAL tool (with CFS instead of Fried’s frailty instrument) has good discriminant power to improve prognostic certainty of short-term mortality for ED physicians in both health systems. This shows promise in enhancing clinician’s confidence in initiating earlier end-of-life discussions

DESIGN PRINCIPLES FOR APP-BASED HEALTHCARE INTERVENTIONS: A MIXED METHOD APPROACH

Despite the ubiquity of mobile health applications (apps), the practical use and success of the apps have been questionable. Design Principles (DP) can affect chronic health app user satisfaction and have been studied for ensuring favorable app usage. However, there is no consensual definition of DP within the preceding literature, which has a technical rather than an end-user-centric focus and lacks a rigorous theoretical basis. Moreover, different levels of DPs’ application can lead to differential user satisfaction as influenced by the user-contextual environment, warranting a quantitative assessment. Accordingly, the overarching question to be addressed is which DP for the self-management of chronic conditions contributes to better user satisfaction outcomes. The research focuses on Multiple Sclerosis (MS) as a representative condition. This research uses a mixed methods, with a qualitative approach for DP identification and a quantitative approach for the studying the DP-Satisfaction relationship. The DP identification is achieved through - 1) An in depth review of foundational theory for greater validity, 2) A Systematic Literature Review (SLR), for DP themes grounded in theory, and 3) Manually coded user reviews for MS apps. The theoretical underpinnings of the empirical approach are established through a composite theoretical lens, based on technologically, behaviorally, and cognitively oriented frameworks. The DP extracted from theory, SLR, and manual coding methods are found to be largely consistent with each other, namely ‘Communication with Clinicians’, ‘Compatibility, ‘Education’, ‘Notifications’, ‘Tracking’, ‘Social Support’, ‘Ease of Use’, ‘Technical Support’, ‘Usefulness’, ‘Privacy and Security’, and Quality. An ordinal logistic regression analysis is conducted to understand the relationship between DP and User Satisfaction outcomes based on the manually coded DP scores of the user reviews. All DP have a significant impact on User Satisfaction. From a theoretical perspective, the research improves our understanding of key design principles for the self-management of chronic conditions such as MS and the impact of such principles on user satisfaction. From a practical perspective, the findings provide guidance to the user requirement elicitation process, potentially leading to the development of more successful, sustainable, and responsive healthcare interventions

Patient and public attitudes to and awareness of clinical practice guidelines : a systematic review with thematic and narrative syntheses

Article Accepted Date: 15 July 2014 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Acknowledgements The research leading to these results has received funding from the European Community’s Seventh Framework Programme (FP7/2007-2013) under grant agreement n° 258583 (DECIDE project). The Health Services Research Unit, Aberdeen University, is funded by the Chief Scientist Office of the Scottish Government Health Directorates. The authors accept full responsibility for this paper and the views expressed in it are those of the authors and do not necessarily reflect those of the Chief Scientist Office. NS receives funding through a Knowledge Translation Fellowship from the Canadian Institutes of Health Research. No funding bodies had a role in the manuscript. We would like to thank Healthcare Improvement Scotland and the University of Dundee for support, including access to literature. We would also like to thank Lorna Thompson (Healthcare Improvement Scotland), for her help with the protocol for this review.Peer reviewedPublisher PD

Exam Room Computers and Patient-Clinician Communication: A Wicked Problem

The present study is a primarily qualitative case study examining the patient-clinician relationship. Clinicians practicing within an oncology practice with a reputation for patient-centered care responded to questions regarding how the introduction of an electronic medical record (EMR) and an exam room computer had affected their day-to-day clinical practice. Framed as a wicked problem (a problem that could not be solved using a linear methodology), I believed clues to understanding a method for incorporating use of an exam room computer into a clinical visit while maintaining empathic communication with the patient could be found by exploring the experience of clinicians who had faced the dilemma. Only three of the nine clinicians interviewed reported routinely using the computer to document the visit while the patient was in the room. The exam room computer was perceived by the clinicians as a third interaction in addition to the patient-clinician relationship and had changed the dynamics of the clinical visit. Identified disadvantages to using an exam room computer included physical environmental factors and relational problems created by system failures or slowness where the clinician felt obligated to explain the unwelcome interruptions of the clinical visit by acknowledging to the patient the interference of the damn computer. Environmental factors interfered with empathic communication by limiting nonverbal communication, particularly eye contact. Similarly, relational factors made empathic communication more difficult by interrupting the flow of conversation or pulling the clinician\u27s attention away from the patient. The clinicians who used the exam room computer in the presence of the patient were unable to verbalize a specific technique they had discovered to unable them to maintain an empathic connection with their patients. However, in explaining how they had adapted their practice after the introduction of the exam room computer they demonstrated a strong commitment to their patients through mindfulness and reflexivity. The empathic connection between these clinicians and their patients was maintained through an awareness of how their words and behavior might be perceived by the patient, and a conscious effort to keep the patient at the center of the interaction despite distractions introduced by the computer

M-health adoption by healthcare professionals : a systematic review

Objective The aim of this systematic review was to synthesize current knowledge of the factors influencing healthcare professional adoption of mobile health (m-health) applications. Methods Covering a period from 2000 to 2014, we conducted a systematic literature search on four electronic databases (PubMed, EMBASE, CINAHL, PsychInfo). We also consulted references from included studies. We included studies if they reported the perceptions of healthcare professionals regarding barriers and facilitators to m-health utilization, if they were published in English, Spanish, or French and if they presented an empirical study design (qualitative, quantitative, or mixed methods). Two authors independently assessed study quality and performed content analysis using a validated extraction grid with pre-established categorization of barriers and facilitators. Results The search strategy led to a total of 4223 potentially relevant papers, of which 33 met the inclusion criteria. Main perceived adoption factors to m-health at the individual, organizational, and contextual levels were the following: perceived usefulness and ease of use, design and technical concerns, cost, time, privacy and security issues, familiarity with the technology, risk-benefit assessment, and interaction with others (colleagues, patients, and management). Conclusion This systematic review provides a set of key elements making it possible to understand the challenges and opportunities for m-health utilization by healthcare providers

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The Development, Implementation, and Evaluation of a Transgender Health Resource Bundle

Transgender populations experience disproportionate social and health disparities that can negatively impact quality of life. Healthcare barriers due to gender based discrimination and lack of medical insurance and culturally competent providers contribute to low levels of access to preventative health care screenings, resulting in sub-optimal health outcomes. The unique health circumstances of transgender individuals have been understudied in the literature. As a result clinicians are often under-informed of their specific health maintenance needs and screening guidelines. To help address this disparity, a Doctor of Nursing Practice (DNP) student at the University of San Francisco facilitated the collaborative assessment, development, implementation and evaluation of a transgender health screening/health maintenance resource bundle at a federally funded community health center in San Francisco, California. The project met its objectives in increasing health provider knowledge regarding transgender health maintenance and in demonstrating its usefulness to the clinic