An Ethnography of Care Coordination in an Integrated Practice Unit for Ventilator Dependent Patients

The growing complexity of healthcare delivery coupled with the pressures to improve cost, quality, and outcomes has healthcare leaders struggling to prioritize initiatives and programs that provide coordinated patient-centered care. It is generally accepted and most academic studies demonstrate that better care coordination will reduce redundancies, improve clinical decision making and provide patients with better care experiences. Moreover, industry leaders are pushing for reforms and policy makers have regulated structural changes aimed at improving the US healthcare system. However, to implement such changes, healthcare organizations must understand the elements of care coordination at the work flow level and how those elements are impacted by the context in which the care is being delivered. Against that backdrop, this ethnographic research of a pediatric clinic designed as an Integrated Practice Unit as defined by Porter and Teisberg examines the care coordination activities between the providers to understand how they are carried out in this specific context, and how infrastructure changes such as the implementation of an enterprise Electronic Health Record impacts the everyday practices of care coordination. As a result, we contribute to the concept of an integrated practice unit by studying it in an operational context and through the lens of Relational Coordination Theory. We make observations regarding the extent to which integrated practice units enhance care coordination and patient value. We also contribute to Relational Coordination Theory itself by demonstrating how “non-core” team members, organizational context, and worker outcomes are observed so that these measures can be addressed quantitatively in the future

Missing Pieces in Health Services Cost Analysis: Consensus on Modeling, Magnitude, and Micro-Costing

Cost and cost savings have become an important focus for health policy administrators. However, there are missing pieces in our approach to cost analysis; there is no consensus on multivariable methods, no indicators of minimally acceptable values, and no specification of process costing. In this dissertation, I propose to fill the gaps in the literature by 1) identifying which methods are appropriate for large claims data, 2) examine existing methods to establish minimally important difference (MID) in health outcomes to identify MID in costs, and 3) determine differences in sick visit clinic costs using a modified micro-costing method. Most models that were compared to the generalized linear models Gamma distribution with log link found it to be the superior model in both simulated data and real administrative data. We recommend that in cases where acceptable anchors are not available to establish an MID, both the Delphi and the distribution-method of MID for costs be explored for convergence. Our micro-costing approach is feasible to use under virtual working conditions; requires minimal provider time; and generates detailed cost estimates that have “face validity” with providers and are relevant for economic evaluation

Determining the effect of an educational intervention on medical support personnel\u27s knowledge to administer a standardized developmental screening tool.

Early treatment of developmental delays leads to improved outcomes for children (Yeung et al., 2014). In order to benefit from early intervention, children with developmental delays must be identified and referred at a young age. Although the use of validated developmental screening tools is supported by American Academy of Pediatrics (AAP) guidelines, these instruments are used variably by general physicians in pediatric practice (King et al., 2010). Because of the expanding work roles of medical support personnel, it is worthwhile to determine if this group can administer and score a developmental screening tool after completing an educational intervention to assist general pediatric practices in using these tools in accordance with the AAP mandate. Currently, no peer-reviewed published research exists regarding training medical support personnel to administer and score a standardized developmental screening tool. Guided by Kirkpatrick’s four-level evaluation model, the current mixed methods study sought to: 1) assess the effect of an educational intervention on the knowledge of medical support personnel in pediatric primary care settings to administer and score a standardized developmental screening tool; 2) determine if the medical support personnel were able to score the selected tool in practice as accurately as the “gold standard”; and 3) report the experience of medical support personnel learning and applying a newly acquired skill in clinical practice. Study participants from three urban pediatric clinics completed a pre- and post-survey and an educational intervention. One participant from each clinic also completed an in-depth interview to describe their experience with the educational intervention and the application of the learned information in practice. Quantitative data analysis indicated that after the educational intervention, the medical support personnel demonstrated a significant increase (p \u3c .020) on knowledge post-test scores (mean 16.69, SD 2.898) from pre-test scores (mean 14.46, SD 2.961). The medical support personnel were also mostly successful in administering and scoring the developmental screener in practice (80%). Qualitatively, study participants indicated that the educational intervention was acceptable, and positively impacted their practice. This project demonstrates that an educational intervention increased the knowledge of medical support personnel regarding developmental screening

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

Usability and Technology Acceptance of an Electronic Child Abuse Screening Tool in a Pediatric Emergency Department

Up to half of all child physical abuse victims with major abuse injuries seen in hospitals had sentinel injuries assessed by medical providers. Universal screening for child abuse and neglect in the emergency department can potentially increase detection at lower levels of injury. However, we must consider usability for the electronic health record embedded child abuse and neglect-screening tool to be most effective. The user most likely to interact with the screening tool is the bedside nurse. The interface of the initial screening tool and the process of inputting information must be perceived as useful, usable, and satisfying to the bedside nurse. The alert for a positive screen needs to achieve the right balance in visual hierarchy and workflow while avoiding alert fatigue and information overload in an already busy space. This project addresses the lack of robust universal child abuse and neglect screening in the Texas Children’s Hospitals’ emergency department. It also aims to address the gap in the literature on electronic health record-embedded child abuse and neglect screening tool usability. In addition, it seeks to address the gap in the literature on child abuse, neglect screening, and response protocols, as well as expand those protocols so they encompass support services for families affected by the sequela of poverty to avoid future states of neglect

A Learning Health Sciences Approach to Understanding Clinical Documentation in Pediatric Rehabilitation Settings

The work presented in this dissertation provides an analysis of clinical documentation that challenges the concepts and thinking surrounding missingness of data from clinical settings and the factors that influence why data are missing. It also foregrounds the critical role of clinical documentation as infrastructure for creating learning health systems (LHS) for pediatric rehabilitation settings. Although completeness of discrete data is limited, the results presented do not reflect the quality of care or the extent of unstructured data that providers document in other locations of the electronic health record (EHR) interface. While some may view imputation and natural language processing as means to address missingness of clinical data, these practices carry biases in their interpretations and issues of validity in results. The factors that influence missingness of discrete clinical data are rooted not just in technical structures, but larger professional, system level and unobservable phenomena that shape provider practices of clinical documentation. This work has implications for how we view clinical documentation as critical infrastructure for LHS, future studies of data quality and health outcomes research, and EHR design and implementation. The overall research questions for this dissertation are: 1) To what extent can data networks be leveraged to build classifiers of patient functional performance and physical disability? 2) How can discrete clinical data on gross motor function be used to draw conclusions about clinical documentation practices in the EHR for cerebral palsy? 3) Why does missingness of discrete data in the EHR occur? To address these questions, a three-pronged approach is used to examine data completeness and the factors that influence missingness of discrete clinical data in an exemplar pediatric data learning network will be used. As a use-case, evaluation of EHR data completeness of gross motor function related data, populated by providers from 2015-2019 for children with cerebral palsy (CP), will be completed. Mixed methods research strategies will be used to achieve the dissertation objectives, including developing an expert-informed and standards-based phenotype model of gross motor function data as a task-based mechanism, conducting quantitative descriptive analyses of completeness of discrete data in the EHR, and performing qualitative thematic analyses to elicit and interpret the latent concepts that contribute to missingness of discrete data in the EHR. The clinical data for this dissertation are sourced from the Shriners Hospitals for Children (SHC) Health Outcomes Network (SHOnet), while qualitative data were collected through interviews and field observations of clinical providers across three care sites in the SHC system.PHDHlth Infrastr & Lrng Systs PhDUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/162994/1/njkoscie_1.pd

Utilizing artificial intelligence in perioperative patient flow:systematic literature review

Abstract. The purpose of this thesis was to map the existing landscape of artificial intelligence (AI) applications used in secondary healthcare, with a focus on perioperative care. The goal was to find out what systems have been developed, and how capable they are at controlling perioperative patient flow. The review was guided by the following research question: How is AI currently utilized in patient flow management in the context of perioperative care? This systematic literature review examined the current evidence regarding the use of AI in perioperative patient flow. A comprehensive search was conducted in four databases, resulting in 33 articles meeting the inclusion criteria. Findings demonstrated that AI technologies, such as machine learning (ML) algorithms and predictive analytics tools, have shown somewhat promising outcomes in optimizing perioperative patient flow. Specifically, AI systems have proven effective in predicting surgical case durations, assessing risks, planning treatments, supporting diagnosis, improving bed utilization, reducing cancellations and delays, and enhancing communication and collaboration among healthcare providers. However, several challenges were identified, including the need for accurate and reliable data sources, ethical considerations, and the potential for biased algorithms. Further research is needed to validate and optimize the application of AI in perioperative patient flow. The contribution of this thesis is summarizing the current state of the characteristics of AI application in perioperative patient flow. This systematic literature review provides information about the features of perioperative patient flow and the clinical tasks of AI applications previously identified

Information Systems and Healthcare XXXIV: Clinical Knowledge Management Systems—Literature Review and Research Issues for Information Systems

Knowledge Management (KM) has emerged as a possible solution to many of the challenges facing U.S. and international healthcare systems. These challenges include concerns regarding the safety and quality of patient care, critical inefficiency, disparate technologies and information standards, rapidly rising costs and clinical information overload. In this paper, we focus on clinical knowledge management systems (CKMS) research. The objectives of the paper are to evaluate the current state of knowledge management systems diffusion in the clinical setting, assess the present status and focus of CKMS research efforts, and identify research gaps and opportunities for future work across the medical informatics and information systems disciplines. The study analyzes the literature along two dimensions: (1) the knowledge management processes of creation, capture, transfer, and application, and (2) the clinical processes of diagnosis, treatment, monitoring and prognosis. The study reveals that the vast majority of CKMS research has been conducted by the medical and health informatics communities. Information systems (IS) researchers have played a limited role in past CKMS research. Overall, the results indicate that there is considerable potential for IS researchers to contribute their expertise to the improvement of clinical process through technology-based KM approaches

Pediatric Bullying and Victimization: Quality Improvement Project in a Primary Care Setting

Bullying is a form of aggression characterized by repeated psychological or physical oppression, which negatively impacts children. More recently, the phenomenon of cyberbullying, or electronic bullying, has become prevalent. Despite efforts by schools to address forms of bullying, young people continue to be victimized. Primary care settings are well placed to address these issues with patients and their families to improve care and outcomes. Screenings and mental health referrals by physicians have been shown to reduce future involvement in bullying and increase access to treatment. When thinking about healthcare improvements in primary care settings, screening has been shown to be useful for addressing concerns that might not have otherwise come up. Prior to the current study, young adolescent patients were going to be screened for bullying during well-child visits and invited for follow-up. Due to the changes in primary care practice caused by the response to the global COVID-19 pandemic, well-child visits were canceled, requiring that the focus of the study be to explore physicians’ perspectives. The current study aimed to explore physicians’ attitudes and beliefs regarding bullying through a qualitative approach with the use of semi-structured individual interviews with primary care providers from one practice. Thematic analysis was conducted. The results yielded providers’ impressions and beliefs about screening for bullying, indicating the utility of screening as a successful tool to gather more information on adolescent victimization to help patients and families address these concerns. Implications, limitations, and future research ideas are also explored

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