Leveraging Knowledge-Based Approaches to Promote Antiretroviral Toxicity Monitoring in Underserved Settings

As access and use of antiretroviral therapy continue to increase, the need to improve antiretroviral toxicity monitoring becomes more critical. This is particularly so in underserved settings, where patterns of antiretroviral toxicities possibly alter the need for and frequency of antiretroviral toxicity monitoring. However, barriers such as few skilled healthcare providers and poor infrastructure make antiretroviral toxicity monitoring in underserved settings difficult. The purpose of this dissertation was to investigate how standard clinical guidelines, knowledge-based clinical decision support, and task delegation could be leveraged to overcome barriers to antiretroviral toxicity monitoring in underserved settings. The strategy adopted in this dissertation was guided by the Design Science Research Methodology that emphasizes the generation of scientific knowledge through building novel artifacts. Two qualitative descriptive studies were conducted to characterize the contextual factors associated with antiretroviral toxicity monitoring in underserved settings. Supported by the findings from these studies, a knowledge-based software application prototype that implements clinical practice guidelines for antiretroviral toxicity monitoring was developed. Next, a quantitative validation study was used to evaluate the structure and behavior of the prototype’s knowledge base. Lastly, a quantitative usability study was conducted to assess lay health worker perceptions of the satisfaction and mental effort associated with the use of checklists generated by the prototype. This dissertation research produced empirical evidence about the broad motives and strategies for promoting medication adherence, safety, and effectiveness in underserved settings. It also identified barriers and facilitators of antiretroviral toxicity monitoring within ambulatory HIV care workflows in underserved settings. Additionally, it provided evidence about the extent to which antiretroviral toxicity domain knowledge could be implemented in a knowledge-based application for supporting point-of-care antiretroviral toxicity monitoring. Lastly, the research provided previously unavailable empirical evidence about the perceptions of lay peer health workers on the use of checklists for the documentation of antiretroviral toxicities

(Re)defining Healthcare Quality: Metrics, Protocols, and the Restructuring of Care Delivery

Healthcare organizations in the United States are increasingly evaluated by systems that link quality measurement with regulatory and payment approaches. Operationalized through quality measurement, quality is affirmed as the basis for improving healthcare processes, outcomes, and health systems broadly. At the same time, electronic health record (EHR) and other information technology (IT) systems aimed to make care safer and more efficient, have become standard tools in healthcare settings. Galvanized by these technical advancements, quality metrics are considered crucial components of ensuring accountability for improved health outcomes and care equity.This dissertation aims to understand healthcare quality measurement by investigating how systems of quality measurement are implemented in clinical spaces, particularly how they structure care delivery and define quality. This dissertation offers a qualitative study of the organizational and structural elements of quality and quality measurement. I conducted ethnographic observation (15 months) and interviews (n=31) at a 600-bed, acute-care hospital in New York City, which I call Borough Hospital. My analysis utilizes the accounts of healthcare clinicians and administrators, and their experiences navigating care delivery and quality in their hospital. Through this analysis, I investigate the variable meanings of quality, processes of measuring quality, and the conditions under which care is delivered at Borough Hospital. Using the qualitative analytic methods of grounded theory and situational analysis, I deconstruct the ways in which quality and quality measurement are constructed as neutral and inevitable, how care delivery is increasingly protocolized to ensure quality, and the ensuing distancing of quality care away from the bedside. Meeting and complying with quality metrics require specific clinical care protocols and extensive documentation for reporting. These new requirements have changed the roles and responsibilities of frontline clinicians, shifting the organization of labor in the clinic. I argue that measurement-based, clinical protocols that rely on surveillance and abstracted documentation data increasingly standardize processes of quality care and distance care—that is, clinician labor— away from the bedside. The findings of this dissertation suggest a tendency toward protocolization and narrowing definitions of quality, which can be extended into other hospital systems particularly in light of widespread consolidation. I argue that administrative prioritization of quality measurement, and in particular quality metrics, necessitates the protocolization of complex healthcare processes and increasingly relies on data-driven decision-making. Ultimately, I suggest quality care has been (re)defined by measurement-based, clinical protocols, which I call abstracted surveillance protocols, that increasingly standardize and constrain care delivery

Medical Device Alarm Systems: a Multi-Hospital Study of Alarm-Related Events, Caregiver Alarm Response, and Their Contributing Factors

Medical device alarm systems are expected to improve patient care by alerting clinicians about conditions that require attention. However, due to a variety of circumstances, including inadequate training, muting alarms, alarm fatigue, and staffing shortages, the effectiveness of alarm systems may be questionable. This research looked at the appropriateness of time- to-respond (TTR) to alarms, the alarm system configuration, policies and procedures regarding alarms, and the extent of alarm-specific training and education alarms. Using concepts from cognitive systems engineering, organization policy, and organizational learning, a research model was assembled to investigate these relationships. Quantitative data analysis included an online survey conducted in four hospitals, retrospective review of alarm data related to patient harms, review of Nurse Call download data used to compare self-report of alarms to actual numbers of alarms as well as to assist in answering exploratory questions. Qualitative data analysis included the clinician survey comments, review of alarm-related policy and procedure, and staff interviews. Alarm survey data were collected from a total of 107 respondents over a three-month timeframe. Data download of alarms totaled 88,307. Using a logistic regression approach, partial support for the hypotheses was found across contexts of high, medium, and low priority alarms. The overall prediction of appropriateness of alarm response was good, except in the case of medium priority alarms. Examination of the alarm data revealed that clinician response to medium priority alarms was considerably slower than anticipated. The results indicated that alarm configuration, policy, education, and training provided some explanation about alarm response. However, resulting data also indicated that the relationship between the alarm priorities and response times are not fully understood. While high priority and low priority alarms were approached appropriately, medium priority alarms did not elicit the same response. This is of some concern given that they form the bulk of the alarms in some hospitals. While alarm configuration, policy and procedures, education and training provided some explanation about alarm response, other factors may contribute to the disparity in response which were not clarified in this research. As more devices with alarm capabilities are introduced into patient care, it is imperative that the appropriate response is elicited in clinicians

The Implementation of Diabetic Foot Care into Primary Care

Diabetes mellitus (DM) is one of the most common metabolic diseases worldwide. It can lead to complications in many parts of the body and can increase overall risk of dying prematurely (World Health Organization (WHO), 2016). Diabetic peripheral neuropathy (DPN) in the feet is one of the most frequent complications of DM (Wang et al., 2017). Other lower extremity complications which can occur as a result of diabetic foot complication (DFC) includes peripheral artery disease (PAD), infection, ulcer and amputation. One of the obstacles for preventing (DFC) is the lack of examinations of the feet in clinical practice (Feitosa et al., 2016). Guided by the Iowa Model Revised (Iowa Model Collaborative, 2017), The purpose of this 12- week project was to implement best practice recommendations for the provision of diabetic foot care into primary care. A review of literature was performed by the project leader (PL) which generated 11 pieces of relevant evidence that met the inclusion criteria. Participants of this project included 531 adult diabetic patients, ages 18-74, who were seen in the primary care setting. Best practice recommendation for interventions included: (a) provider history and foot physical assessment including provider use of the Semmes-Weinstein Monofilament (SWM) tool to assess for actual diabetic foot complication, (b) assessment of footwear, (c) provision of patient education, and (d) initiating multidisciplinary care by educating clinicians, planning a workflow, and providing ongoing feedback. The primary outcome measured was appropriate referrals, defined as a referral to the specialty clinic that is ordered by the provider for individuals with a SWM tool score of 3 and a ‘yes” for referral that has been documented by the provider in the EMR. Findings showed that the interventions improved appropriate referral (X2(1) = 72.657; p \u3c.001), as well as the secondary outcomes of provider foot assessment (X2(1) =93.209; p \u3c.001) and patient follow-up compliance to the Podiatry clinic (PC) following referral (X2(1) = 88.7014; p \u3c.001)

The Implementation of Diabetic Foot Care into Primary Care

Diabetes mellitus (DM) is one of the most common metabolic diseases worldwide. It can lead to complications in many parts of the body and can increase overall risk of dying prematurely (World Health Organization (WHO), 2016). Diabetic peripheral neuropathy (DPN) in the feet is one of the most frequent complications of DM (Wang et al., 2017). Other lower extremity complications which can occur as a result of diabetic foot complication (DFC) includes peripheral artery disease (PAD), infection, ulcer and amputation. One of the obstacles for preventing (DFC) is the lack of examinations of the feet in clinical practice (Feitosa et al., 2016). Guided by the Iowa Model Revised (Iowa Model Collaborative, 2017), The purpose of this 12- week project was to implement best practice recommendations for the provision of diabetic foot care into primary care. A review of literature was performed by the project leader (PL) which generated 11 pieces of relevant evidence that met the inclusion criteria. Participants of this project included 531 adult diabetic patients, ages 18-74, who were seen in the primary care setting. Best practice recommendation for interventions included: (a) provider history and foot physical assessment including provider use of the Semmes-Weinstein Monofilament (SWM) tool to assess for actual diabetic foot complication, (b) assessment of footwear, (c) provision of patient education, and (d) initiating multidisciplinary care by educating clinicians, planning a workflow, and providing ongoing feedback. The primary outcome measured was appropriate referrals, defined as a referral to the specialty clinic that is ordered by the provider for individuals with a SWM tool score of 3 and a ‘yes” for referral that has been documented by the provider in the EMR. Findings showed that the interventions improved appropriate referral (X2(1) = 72.657; p \u3c.001), as well as the secondary outcomes of provider foot assessment (X2(1) =93.209; p \u3c.001) and patient follow-up compliance to the Podiatry clinic (PC) following referral (X2(1) = 88.7014; p \u3c.001)

Technology-Enhanced Practice for Patients with Chronic Cardiac Disease: Home Implementation and Evaluation

Objective: This 3-year field experiment engaged 60 nurses and 282 patients in the design and evaluation of an innovative home-care nursing model, referred to as technology-enhanced practice (TEP). Methods: Nurses using TEP augmented the usual care with a web-based resource (HeartCareII) that provided patients with self-management information, self-monitoring tools, and messaging services. Results: Patients exposed to TEP demonstrated better quality of life and self-management of chronic heart disease during the first 4 weeks, and were no more likely than patients in usual care to make unplanned visits to a clinician or hospital. Both groups demonstrated the same long-term symptom management and achievements in health status. Conclusion: This project provides new evidence that the purposeful creation of patient-tailored web resources within a hospital portal is possible; that nurses have difficulty with modifying their practice routines, even with a highly-tailored web resource; and that the benefits of this intervention are more discernable in the early postdischarge stages of care

Transactions of 2019 International Conference on Health Information Technology Advancement Vol. 4 No. 1

The Fourth International Conference on Health Information Technology Advancement Kalamazoo, Michigan, October 31 - Nov. 1, 2019. Conference Co-Chairs Bernard T. Han and Muhammad Razi, Department of Business Information Systems, Haworth College of Business, Western Michigan University Kalamazoo, MI 49008 Transaction Editor Dr. Huei Lee, Professor, Department of Computer Information Systems, Eastern Michigan University Ypsilanti, MI 48197 Volume 4, No. 1 Hosted by The Center for Health Information Technology Advancement, WM

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Compiles peer-reviewed research and literature reviews on issues regarding patient safety and quality of care, ranging from evidence-based practice, patient-centered care, and nurses' working conditions to critical opportunities and tools for improvement

Evidence-Based Best Practice Toolkit for Competency-Based Orientation in Integrating an Adult Pneumococcal Protocol to Improve Vaccine Rate: A Program Evaluation Review

Practice Problem: Low pneumococcal vaccine uptake among high-risk adults is partly due to underutilized or lack of nurse-driven vaccine protocols, limited understanding of vaccine intervals and indications by nurses, and lack of proper training. Currently, physician-driven orders are the only avenue for high-risk adults to obtain this vaccine in ambulatory sites. PICOT: In adults 65 years or older within an ambulatory setting, does the use of an adult pneumococcal vaccine protocol, compared to a physician order (no vaccine protocol) impact the rate of vaccination over 2 months? Evidence: Utilization of two or more interventions provided higher immunization rates. Interventions with stronger evidence rate include nurse-driven vaccine protocols, vaccine reminders, and use of electronic health system alerts. Review of programs and toolkits proved efficient interventions of vaccine programs based on CDC program evaluation framework. Intervention: The program evaluation yielded best practices for adult pneumococcal vaccine compliance utilizing nurse-driven protocols based on CDC recommendations and a competency-based orientation toolkit to support staff members when working in ambulatory settings. Outcome: A CBO toolkit was created to facilitate the ordering and administration of pneumococcal vaccines based on approved protocol to increase vaccine uptake. CBO toolkits offer nurses autonomy and increased competency with safe injection practices. Conclusion: Adult vaccine programs with nurse-driven protocols in combination with other modalities, prove effective to increase pneumococcal vaccine rates among high-risk groups and expands access to preventive health services provided by nursing staff. A CBO toolkit increases competency of injection practices of nurses in ambulatory settings

Efficient Decision Support Systems

This series is directed to diverse managerial professionals who are leading the transformation of individual domains by using expert information and domain knowledge to drive decision support systems (DSSs). The series offers a broad range of subjects addressed in specific areas such as health care, business management, banking, agriculture, environmental improvement, natural resource and spatial management, aviation administration, and hybrid applications of information technology aimed to interdisciplinary issues. This book series is composed of three volumes: Volume 1 consists of general concepts and methodology of DSSs; Volume 2 consists of applications of DSSs in the biomedical domain; Volume 3 consists of hybrid applications of DSSs in multidisciplinary domains. The book is shaped decision support strategies in the new infrastructure that assists the readers in full use of the creative technology to manipulate input data and to transform information into useful decisions for decision makers