Barriers and Facilitators Influencing Compliance with Enhanced Recovery After Surgery Protocol: A Qualitative Study

Standardization in many industries has proven to lead to improved productivity and efficiency, however, standard practice in healthcare has proven difficult due to patient and physician variation. Evidence-based practices provide an opportunity to create more standardization. Enhanced Recovery After Surgery (ERAS) programs are attempting to standardize the surgical pathways of patients by implementing standard evidence-based steps, beginning in the surgeons office and continuing through a patients discharge (Ljungqvist, Scott, & Fearon, 2017). Implementing ERAS to standardize the surgical care of patients has shown to improve patient outcomes, reduce length of stay and reduce readmissions, however, there is a lack of studies detailing the implementation process to be successful. A literature review by Stone et al. (2018) found only 53 papers on ERAS that discussed implementation. The review organized barriers and facilitators using the Consolidated Framework for Implementation Research (CFIR). The CFIR is a framework organized with five domains and constructs within each domain that could affect implementation (Damschroder et al., 2009). The purpose of this research is to detail implementation and identify barriers and facilitators that impact compliance with an ERAS protocol for colorectal surgery. This research begins by detailing seven steps taken prior to implementing ERAS. Compliance with 19 of the ERAS components will be tracked to measure improvements over the implementation timeline. The first objective is to measure if compliance with the process measures increased from the pre-implementation to post-implementation. The second objective is to measure if implementation leads to a decrease in length of stay. The third objective is to identify barriers and facilitators with implementation by conducting semi structured focus groups with nursing, surgeons, anesthesia and leadership. The outcome of these findings will be an implementation framework. The results of this study showed a significant increase in compliance with 10 of the process measures as well as a significant decrease in length of stay, as measured by a t-test. The semistructured focus groups analyzed by the CFIR indicated that inner setting and implementation plan were the most discussed. Key facilitators to implementation were gaining leadership support and engagement, establishing a multidisciplinary team that meets regularly, and showing process measure and outcome data as feedback. These items are essential to implementation of an ERAS protocol

Effectiveness of User Centered Design for Optimizing an Electronic Documentation Form

Problem. The electronic form used by lactation consultants to document assessment findings, interventions, plans and recommendations, did not meet user’s requirements. Purpose: The purpose of this project was to evaluate the effect of optimization through a User Centered Design (UCD) process on information quality, use and user satisfaction. Goals. The goals were to provide information technology (IT) support for the organization’s Baby Friendly initiative and to support collaborative, consistent messaging for breastfeeding families which could, in turn, support exclusive breast milk feeding. Exclusive breast milk feeding is a population health initiative that could positively impact the triple aim of better care, lower costs and better health. Objectives. Information quality, use and user satisfaction affect user adoption and acceptance of IT solutions. The objective of this project was to test the effectiveness of UCD on optimization by measuring the increase in information quality, use and user satisfaction after implementation of an optimized electronic lactation assessment. Plan. Stakeholders were identified and the electronic form was optimized through UCD. A pre-test/post-test quasi-experimental design was chosen to measure the effect of optimization. Instruments included a modified version of the System and Use Assessment Survey (AHRQ, n.d.), a chart audit tool and an electronic data warehouse use query. IRB approval was obtained from COMIRB and Regis University. The pre and post data collection periods were each six weeks in length, allowing for a two week chart audit period and four week survey. The intervention was implemented after the close of the pre-test period. Clinical users were educated following the organization’s usual methods for EHR changes. Five months after the intervention, the study timeline was repeated for the post-test period. After the post-test period, a use query was run to collect data for both pre-test and post-test periods. Data were collected, coded, and entered into electronic spreadsheets for storage and analysis. Outcomes and Results. Although the sample as a whole showed no statistically significant increases in any parameter of information quality, use, or user satisfaction, when survey participants were divided by role, nurses and providers, there was a statistically significant increase in the post-test nursing group for two measures of information quality and one measure of information use. A Mann Whitney U test found a significantly higher perception of completeness of the lactation assessment, U = 200, z = -2.11, p = .035, r = .29 and reported frequency of accessing the lactation assessment from the EHR, U= 233, z = -2.01, p = .044, r = 0.26. A Fishers exact test found a statistically significant increase in the presence of lactation assessments in the post-test chart audit [1, N = 39] = 11.8, p =.001, φ= .39). The outcomes may be explained by differences in how each role uses the EHR. Additional education for providers may be necessary to overcome these differences

Baylor Health Care System: High-Performance Integrated Health Care

Describes the organization's implementation of a quality infrastructure and its strategies, interventions to improve clinical preventive services, training, and adoption of electronic health records and other quality innovations. Outlines lessons learned

Constructive eHealth evaluation:Lessons from evaluation of EHR development in 4 Danish hospitals

Abstract Background Information and communication sources in the healthcare sector are replaced with new eHealth technologies. This has led to problems arising from the lack of awareness of the importance of end-user involvement in eHealth development and of the difficulties caused by using traditional summative evaluation methods. The Constructive eHealth evaluation method (CeHEM) provides a solution to these problems by offering an evaluation framework for supporting and facilitating end-user involvement during all phases of eHealth development. The aim of this paper is to support this process by sharing experiences of the eHealth evaluation method used in the introduction of electronic health records (EHR) in the North Denmark Region of Denmark. It is the first time the fully developed method and the experiences on using the CeHEM in all five phases of a full lifecycle framework is presented. Methods A case study evaluation of the EHR development process in the North Denmark Region was conducted from 2004 to 2010. The population consisted of clinicians, IT professionals, administrators, and vendors. The study involved 4 hospitals in the region. Data were collected using questionnaires, observations, interviews, and insight gathered from relevant documents. Results The evaluation showed a need for a) Early involvement of clinicians, b) The best possible representation of clinicians, and c) Workload reduction for those involved. The consequences of not providing this were a lack of ownership of decisions and negative attitudes towards the clinical benefits related to these decisions. Further, the result disclosed that by following the above recommendations, and by providing feedback to the 4 actor groups, the physicians’ involvement was improved. As a result they took ownership of decisions and gained a positive attitude to the clinical benefits. Conclusions The CeHEM has proven successful in formative evaluation of EHR development and can point at important issues that need to be taken care of by management. The method provides a framework that takes care of feedback and learning during eHealth development. It can thus support successful eHealth development in a broader context while building on a well-known success factor: end-user involvement in eHealth development

Improving health and public safety through knowledge management

This paper reports on KM in public healthcare and public safety. It reflects the experiences of the author as a CIO (Chief Information Officer) in both industries in Australia and New Zealand. There are commonalities in goals and challenges in KM in both industries. In the case of public safety a goal of modern policing theory is to move more towards intelligence-driven practice. That means interventions based upon research and analysis of information. In healthcare the goals include investment in capacity based upon knowledge of healthcare needs, evidence-based service planning and care delivery, capture of information and provision of knowledge at the point-of-care and evaluation of outcomes. The issue of knowledge management is explored from the perspectives of the user of information and from the discipline of Information Technology and its application to healthcare and public safety. Case studies are discussed to illustrate knowledge management and limiting or enabling factors. These factors include strategy, architecture, standards, feed-back loops, training, quality processes, and social factors such as expectations, ownership of systems and politics

The Use of Clinical Decision Support to Improve Nursing Practice

Healthcare information technology is solidly entrenched in most acute care hospitals but the need to demonstrate its positive impact on patient outcomes persists. Clinical decision support (CDS) is an informatics tool that is highly customizable to promote patient improvement activities. Despite its high potential, studies have had mixed results regarding the impact of CDS and it has not been widely studied in the realm of nursing practice. One aim of this dissertation was to analyze the concept of CDS in order to inform the examination of the relationships between CDS implementation and nursing interventions. The determining factors of nurses use and acceptance of CDS was also described within the context of the CDS concept schematic developed. Data from 4718 pediatric hospital admissions were analyzed to examine if there was a relationship between the implementation of CDS and the implementation of sequential compression devices (SCD) for the purpose of preventing VTE and the placement of chart notifications of VTE risk. Admissions with patients who were identified as at risk for VTE had SCDs placed almost two and one-half times more often after the CDS was implemented (RR = 2.32; 95% CI (1.9 – 2.83)) and 33 times more likely to have chart notifications placed. In order to describe the determining factors of use, the unified theory of acceptance and use of technology (UTAUT) was adapted to create an electronic survey. Two multivariate regression models were built to describe the UTAUT model from previous literature. Results demonstrated that the model as described explains the majority of the data but also highlighted some weaknesses in the realm of the construct voluntary use. The results of this dissertation contribute to the limited literature regarding CDS use in nursing practice

Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating

For more information about the Information Experience Laboratory, visit http://ielab.missouri.edu/Electronic medical record (EMR) adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available. Achieving the healthcare reform goals of broad EMR adoption and “meaningful use” will require that efficiency and usability be effectively addressed at a fundamental level. We conducted a literature review of usability principles, especially those applicable to EMRs. The key principles identified were simplicity, naturalness, consistency, minimizing cognitive load, efficient interactions, forgiveness and feedback, effective use of language, effective information presentation, and preservation of context. Usability is often mistakenly equated with user satisfaction, which is an oversimplification. We describe methods of usability evaluation, offering several alternative methods for measuring efficiency and effectiveness, including patient safety. We provide samples of objective, repeatable and cost‐efficient test scenarios applicable to evaluating EMR usability as an adjunct to certification, and we discuss rating schema for scoring the results. (42 pages

Using Electronic Health Records to Mitigate Workplace Burnout Among Clinicians During the COVID-19 Pandemic: Field Study in Iran

Background: The COVID-19 pandemic spread worldwide in 2020. Notably, in the countries dealing with massive casualties, clinicians have worked in new conditions characterized by a heavy workload and a high risk of being infected. The issue of clinician burnout during the pandemic has attracted considerable attention in health care research. Electronic health records (EHRs) provide health care workers with several features to meet a health system\u27s clinical needs. Objective: We aim to examine how the use of EHR features affects the burnout of clinicians working in hospitals that have special wards for confirmed COVID-19 cases. Methods: Using an online survey, we collected data from 368 physicians, physician assistants, and nurses working in six hospitals that have implemented EHRs in the city of Tehran in Iran. We used logistic regression to assess the association between burnout and awareness of EHR features, EHR system usability, concerns about COVID-19, technology solutions, hospital technology interventions, hospital preparedness, and professional efficacy adjusted for demographic and practice characteristics. Results: The primary outcome of our study was self-reported burnout during the COVID-19 pandemic. Of the 368 respondents, 36% (n=134) reported having at least one symptom of burnout. Participants indicated that the leading cause of EHR-related stress is inadequate training for using technology (n=159, 43%), followed by having less face-to-face time with patients (n=140, 38%). Positive perceptions about the EHR\u27s ease of use were associated with lower odds of burnout symptoms. More interventions, such as clear communication of regulations; transparency in policies, expectations, and goals regarding the use of technology in the clinical workflow; and hospital preparedness to cope with the challenges of the pandemic, were associated with lower odds of burnout. Conclusions: The use of EHR applications, hospital pandemic preparation programs, and transparent technology-related policies and procedures throughout the epidemic can be substantial mitigators of technology-based stress and clinician burnout. Hospitals will then be better positioned to devise or modify technology-related policies and procedures to support physicians\u27 and nurses\u27 well-being during the COVID-19 pandemic. Training programs, transparency in communications of regulations, and developing a clear channel for informing clinicians of changes in policies may help reduce burnout symptoms among physicians and nurses during a pandemic. Providing easily accessible mentorship through teleconsultation and 24-hour available information technology support may also help to mitigate the odds of burnout

Priority 1

The CNL theme I have targeted is the development and use of Informatics and Healthcare Technologies. My project developed a method of measuring KPIs within a new EHR specifically tailored for jail health populations. The development of a Jail Health Services dashboard is modeled after the dashboard developed by California Correctional Health Care Services for the California prison population. The clinicians requested the ability to measure how many Priority 1 visits were seen within 24 hours so it could be determined whether the jail was meeting the NCCHC benchmark of 85%. Previously, Jail Health Services had no way to measure this indicator for access to care. The baseline measurement turned out to be 84.55% with an average of 87.5% over the next five months. We then wished to see if our increase in Priority 1 percentages correlated with a decrease in unscheduled ED visits. The January to June ED visits in 2015 showed a significant decline when compared to the January to June ED visits in 2014. However, a direct correlation was unable to be established because we did not have KPI measurements in 2014 as the EHR was not implemented until late November, 2014. The Triage and Intake training nurses also received extensive training and education regarding the assessment and rejection of prisoner-patients at Triage until evaluated further and receiving clearance from SFGH. The increased rejection of acutely ill patients may have had a much greater impact on the subsequent decrease in unscheduled ED visits in 2015. The establishment of a quantitative method of inquiry into KPI measures created a significant positive impact on the clinicians and nurses with greatly enhanced motivation for further study of care provision aided by the use of our new EHR