Patient Handoffs between Emergency Department and Inpatient Physicians: A Qualitative Study to Inform Standardization of Practice and Organization Theory

This dissertation is motivated by two problems. First, existing literature characterizes patient handoff as an information transfer activity in which safety and quality are compromised by practice variation. This has prompted a movement to standardize practice. However, existing research has not closely examined how practice variations may be responses to situational and organizational factors or evidence of involved parties accomplishing important functions beyond information transfer. Consequently, standardization efforts run at least two risks: overlooking opportunities for improvement, and engendering negative unintended consequences. Second, despite the fact that roughly 50% of all hospitalized patients are handed off from emergency departments to inpatient units, such handoffs are significantly understudied. I conducted a two-year ethnographic study of handoffs occurring between Emergency Department and General Medicine physicians when patients were admitted to one highly-specialized tertiary referral, teaching hospital. Using theoretical sampling informed by a Grounded Theory methodology, I conducted observations (n=349 hours) and semi-structured interviews (n=48) and recorded handoff conversations (n=48). I analyzed data by means of immersion, various qualitative coding approaches, and memo writing. Findings are organized in three chapters. First, I challenge the dominant model of handoff as information transfer by demonstrating that physicians actively construct understandings of their patients, over time, as they encounter, interpret, assemble, and reassemble information through socially-interactive processes within particular contexts and situations. Consequently, multiple understandings of a single patient are not only possible but likely. Second, I characterize admission handoffs as negotiations, situated by entangled webs of motives and concerns which produce ambiguities. Involved parties must navigate these ambiguities as they develop their differing understandings of patients, resolve conflicts over approaches to care, and agree regarding additional work. Third, I show that boundaries between units are ongoing, effortful accomplishments, re-enacted through interactive negotiations. Over time these negotiations have the potential to shift boundaries and alter the divisions of labor in the hospital, with potential consequences for organizational outcomes. Recommendations for practical improvements and further research are presented.Ph.D.InformationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/86293/1/bhilligo_1.pd

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

A Team-Based Approach to Studying Complex Healthcare Processes

Communication is a critical aspect of clinical work. In 2010, the Joint Commission (JC) found that gaps in communication were among leading factors contributing to medical errors. Healthcare processes, such as patient discharge, depend on interdisciplinary communication to be successful. Electronic health records (EHRs) have the potential to facilitate communication and information sharing between interdisciplinary care team members; however, challenges remain in designing tools for team-based care and questions remain in understanding how EHRs impact interdisciplinary team communication. This dissertation focuses on understanding how EHRs can be designed to support communication and information sharing within interdisciplinary patient care teams. The first aim of the dissertation investigated how EHRs impact interdisciplinary clinical teams’ communication, shared mental models, and information sharing activities. The results showed that implementing new EHR tools appeared to have little impact on communication and shared mental models, but new information sharing activities mediated by EHR developed. These changes and lack thereof suggest that new EHR tools will be specifically needed to facilitate interdisciplinary team information sharing activities. The second aim of the dissertation investigates the information sharing activities and information needs of interdisciplinary team members during patient discharge. The results showed that the information clinicians sought out during discharge depended on the roles that person played as well as the progress of the discharge process. Future EHR tools should be aware of how patient care teams are progressing through the patient discharge process in order to provide information contextualized to their current tasks. In conclusion, interdisciplinary team communication and information sharing remain poorly supported by current EHRs and new tools designed specifically for interdisciplinary teams should provide information based on the completion of team activities

Lung cancer: sex difference in the lifetime risk and 10-year risk between 1995 and 2013 in a Swiss population

Introduction: In Switzerland, lung cancer is a leading cause of cancer death. Because smoking is the major cause of lung cancer, trends in lung cancer incidence are following trends in smoking habits in the population, with a latency time of about 30 years. In Switzerland, there was a peak in men’s lung cancer incidence in the 1980s, followed by a decrease until now. Among women, the incidence has increased since the 1970s and, apparently, has not yet reached a peak. Because cancers are feared diseases, an adequate communication about the individual risk of developing cancer is important. Mortality and incidence are traditionally used to assess cancer burden. However, these metrics are difficult to interpret at the individual level. Providing the lifetime and 10-year risk of cancer could improve risk communication for patients and health professionals. Our aim was to estimate trends in the lifetime and 10-year risk of lung cancer, in men and women, between 1995 and 2013

Is overdiagnosis of prostate cancer leveling off? Recent changes in incidence and surgery rates in Switzerland

Many western countries, including Switzerland. Various organizations have recently recommended against routine screening, notably due to the high risk of overdiagnosis or overtreatment. Our aim was to examine whether recent changes in secular trends in the incidence and mortality of prostate cancer, as well as prostatectomy rates have been observed in Switzerland

Interactive Natural Language Processing for Clinical Text

Free-text allows clinicians to capture rich information about patients in narratives and first-person stories. Care providers are likely to continue using free-text in Electronic Medical Records (EMRs) for the foreseeable future due to convenience and utility offered. However, this complicates information extraction tasks for big-data applications. Despite advances in Natural Language Processing (NLP) techniques, building models on clinical text is often expensive and time-consuming. Current approaches require a long collaboration between clinicians and data-scientists. Clinicians provide annotations and training data, while data-scientists build the models. With the current approaches, the domain experts - clinicians and clinical researchers - do not have provisions to inspect these models or give direct feedback. This forms a barrier to NLP adoption and limits its power and utility for real-world clinical applications. Interactive learning systems may allow clinicians without machine learning experience to build NLP models on their own. Interactive methods are particularly attractive for clinical text due to the diversity of tasks that need customized training data. Interactivity could enable end-users (clinicians) to review model outputs and provide feedback for model revisions within an closed feedback loop. This approach may make it feasible to extract understanding from unstructured text in patient records; classifying documents against clinical concepts, summarizing records and other sophisticated NLP tasks while reducing the need for prior annotations and training data upfront. In my dissertation, I demonstrate this approach by building and evaluating prototype systems for both clinical care and research applications. I built NLPReViz as an interactive tool for clinicians to train and build binary NLP models on their own for retrospective review of colonoscopy procedure notes. Next, I extended this effort to design an intelligent signout tool to identify incidental findings in a clinical care setting. I followed a two-step evaluation with clinicians as study participants: a usability evaluation to demonstrate feasibility and overall usefulness of the tool, followed by an empirical evaluation to evaluate model correctness and utility. Lessons learned from the development and evaluation of these prototypes will provide insight into the generalized design of interactive NLP systems for wider clinical applications

Representing and Redefining Specialised Knowledge: Medical Discourse

This volume brings together five selected papers on medical discourse which show how specialised medical corpora provide a framework that helps those engaging with medical discourse to determine how the everyday and the specialised combine to shape the discourse of medical professionals and non-medical communities in relation to both long and short-term factors. The papers contribute, in an exemplary way, to illustrating the shifting boundaries in today’s society between the two major poles making up the medical discourse cline: healthcare discourse at the one end, which records the demand for personalised therapies and individual medical services; and clinical discourse the other, which documents research into society’s collective medical needs