abstract: Clinicians confront formidable challenges with information management and coordination activities. When not properly integrated into clinical workflow, technologies can further burden clinicians’ cognitive resources, which is associated with medical errors and risks to patient safety. An understanding of workflow is necessary to redesign information technologies (IT) that better support clinical processes. This is particularly important in surgical care, which is among the most clinical and resource intensive settings in healthcare, and is associated with a high rate of adverse events. There are a growing number of tools to study workflow; however, few produce the kinds of in-depth analyses needed to understand health IT-mediated workflow. The goals of this research are to: (1) investigate and model workflow and communication processes across technologies and care team members in post-operative hospital care; (2) introduce a mixed-method framework, and (3) demonstrate the framework by examining two health IT-mediated tasks. This research draws on distributed cognition and cognitive engineering theories to develop a micro-analytic strategy in which workflow is broken down into constituent people, artifacts, information, and the interactions between them. It models the interactions that enable information flow across people and artifacts, and identifies dependencies between them. This research found that clinicians manage information in particular ways to facilitate planned and emergent decision-making and coordination processes. Barriers to information flow include frequent information transfers, clinical reasoning absent in documents, conflicting and redundant data across documents and applications, and that clinicians are burdened as information managers. This research also shows there is enormous variation in how clinicians interact with electronic health records (EHRs) to complete routine tasks. Variation is best evidenced by patterns that occur for only one patient case and patterns that contain repeated events. Variation is associated with the users’ experience (EHR and clinical), patient case complexity, and a lack of cognitive support provided by the system to help the user find and synthesize information. The methodology is used to assess how health IT can be improved to better support clinicians’ information management and coordination processes (e.g., context-sensitive design), and to inform how resources can best be allocated for clinician observation and training. / Dissertation/Thesis / Doctoral Dissertation Biomedical Informatics 2017

Introduction: This research investigated the requirements of an HIT solution that is usable and useful to informal caregivers of cancer patients on home palliative care. Methodology: A needs assessment method was used with an exploratory and a confirmatory stage. Eight semi-structured interviews and two focus groups were used for data collection. Qualitative content analysis was used to analyse caregiver experiences with both inductive and deductive coding. Results/Discussion: Expressed and unexpressed caregiver needs were extracted into four categories, Implementation, Presentation, Information, and Practical Caregiving, and used to create the application requirements. Five user personas were created based on caregiving intensity and the functional level of the patients, a method of tailoring the application content to the different personas was created, and a low-fidelity prototype of the application was designed. Conclusion: The findings of this research can improve the preparedness and coping of informal caregivers of cancer patients on home palliative care.

Health information technology (HIT) aims to improve healthcare services by means of technological tools. Patient centered technologies such as personal health records are relatively new HIT tools that enable individuals to get involved in their health management activities. These tools enable the transformation of health consumer behavior from one of passive health information consumers to that of active managers of their health information. This new role is more interactive and engaged, and with such tools, patients can better navigate their lives, and exercise more control over their treatments, hence potentially also leading to improvement in the quality of health services. Despite the benefits of using personal health record systems for health consumers, the adoption rate of these systems remains low. Many free and paid services have not received the uptake that had been anticipated when these services were first introduced. This study investigates some factors that affect the adoption of these systems, and may shed light on some potential reasons for low adoption rates. In developing the theoretical model of this study, social cognitive theory (SCT) and technology acceptance model (TAM) were utilized. The theoretical model was validated through a quantitative survey-based methodology, and the results were derived using structural equation modeling techniques. The key findings of this study highlight the role of individual and environmental factors as determinants of end-user behavior in the adoption of personal health records. The results show that in addition to perceptions of usefulness and ease of use, factors such as social norms and technology awareness are also significantly associated with various factors that directly and indirectly affect intention to use PHRs Based on the results obtained in this study, recommendations are offered for technology providers, and possible directions are proposed for academic researchers.

Despite advances in health care over the past decades, medical errors and omissions remain significant threats to patient safety and health. A large number of these mistakes are made by trainees, persons who are just beginning to build the case-based experiences that will transform them from novices to expert practitioners. Clinicians use both intuitive and deductive problem-solving skills in caring for patients and they acquire expertise in applying these skills through interaction with many and varied cases. The contemporary heath care environment, with decreased lengths of stay for patients and reduced duty hours for trainees, makes getting optimal patient exposure difficult. Virtual patients (VPs), online, interactive patient cases, may help close the case exposure gap. Evidence has shown that VPs improve clinical reasoning skills, but no formal instructional design theory of VPs has been advanced. The goal was to conduct formative research to develop an instructional design theory of VPs to help novice clinicians cultivate clinical reasoning and diagnostic skills. The instructional design theory, goal-based scenarios (GBS), grounded in the learning theory, Case-based Reasoning, provided methods that promised to be appropriate to the goal. An existing, two-module, multimedia VP, Matt Lane, A Pressure Ulcer Prevention Virtual Patient, was tested with 10 medical trainees to determine which methods of GBS it incorporated and which of its methods were not part of GBS. Leaners' experience of what worked and didn't work to promote learning in the VP was analyzed. The VP was found to incorporate all GBS methods and one significant method, the Life Model, that was not part of GBS. The Life Model Method involved replicating, with a high degree of fidelity, the experiences of a real patient in creating the VP scenario. Recommendations for customization of GBS for VPs included more explicit advertisement of learning goals and leverage of Internet search engines to provide just-in-time resources to support problem-solving. Incorporation of the Life Model was also recommended along with the Simplifying Conditions Method from Elaboration Theory to manage the complexity inherent in the Life Model. The resultant, enhanced GBS theory may be particularly relevant in teaching patient-centered care.

Some hospital leaders lacked strategies for implementing electronic medical record (EMR) systems. The purpose of this case study was to explore successful strategies that hospital leaders used in implementing EMR systems. The target population consisted of hospital leaders who succeeded in implementing EMR systems in a single healthcare organization located in the Los Angeles, California region. The conceptual framework used was Kotter's (1996) eight-step process for leading change, and data were collected from face-to-face recorded interviews with 5 participants and from company documents related to EMR design and development. Data were analyzed through methodological triangulation of data types, and exploring codes exhibiting high frequencies to identify principal themes and subthemes. The data coding revealed three primary themes. The first theme related to strategies addressing training, technology, and catalyzing team effort. The second theme related to strategies focusing on employees' concerns, and the third theme related to strategies for designing, developing, and disseminating workflow. The findings affirmed the conceptual framework of Kotter (1996) inasmuch as they showed that participating hospital leaders used one or more steps in Kotter's eight-stage process of creating, implementing, and sustaining significant change. The findings could effect social change by improving the quality of healthcare services provided to patients, which can subsequently benefit patients' families and communities through reducing the costs of healthcare.

A new hospital in United Arab Emirates (UAE) plans to adopt health information technology (HIT) and become fully digitalized once operational. The hospital has identified a need to assess basic computer literacy of new employees prior to offering them training on various HIT applications. Lack of research in identifying an accurate assessment method for basic computer literacy among health care professionals led to this explanatory correlational research study, which compared self-assessment scores and a simulated actual computer skills test to find an appropriate tool for assessing computer literacy. The theoretical framework of the study was based on constructivist learning theory and self-efficacy theory. Two sets of data from 182 hospital employees were collected and analyzed. A t test revealed that scores of self-assessment were significantly higher than they were on the actual test, which indicated that hospital employees tend to score higher on self-assessment when compared to actual skills test. A Pearson product moment correlation revealed a statistically weak correlation between the scores, which implied that self-assessment scores were not a reliable indicator of how an individual would perform on the actual test. An actual skill test was found to be the more reliable tool to assess basic computer skills when compared to self-assessment test. The findings of the study also identified areas where employees at the local hospital lacked basic computer skills, which led to the development of the project to fill these gaps by providing training on basic computer skills prior to them getting trained on various HIT applications. The findings of the study will be useful for hospitals in UAE who are in the process of adopting HIT and for health information educators to design appropriate training curricula based on assessment of basic computer literacy.

Health portals are dedicated web pages for medical practices to provide patients access to their electronic health records. The problem identified in this quality improvement project was that the health portal in the urgent care setting had not been available to staff nor patients. To provide leadership with information related to opening the portal, the first purpose of the project was to assess staff and patients' perceived use, ease of use, attitude toward using, and intention to use the portal. The second purpose was to evaluate the portal education materials for the top 5 urgent care diagnoses: diabetes, hypertension, asthma, otitis media, and bronchitis for understandability and actionability using the Patient Education Material Assessment Tool, Simple Measures of Goobledygook, and the Up to Date application. The first purpose was framed within the technology acceptance model which used a 26-item Likert scale ranging from -3 (total disagreement) to +3 (total agreement). The staff (n = 8) and patients (n = 75) perceived the portal as useful (62%; 60%), easy to use (72%; 70%), expressed a positive attitude toward using (71%; 73%), and would use the technology (54%; 70%). All materials were deemed understandable (74%-95%) with 70% being the acceptable percentage. Diabetes, otitis media, and bronchitis were deemed actionable (71-100%), but hypertension (57%) and asthma (40%) had lower actionability percentages. Hypertension, asthma, and otitis media had appropriate reading levels (6-8th grade). However, diabetes (10th grade) and bronchitis (12th grade) were higher with the target being less than 8th grade level. All handouts were found to be evidence-based. Recommendations were to revise the diabetes and bronchitis educational handouts to improve readability. Social change can be promoted by this project by facilitating positive patient outcomes at urgent care clinics.

Background: Shared decision-making (SDM) counseling for lung cancer screening is recommended by multiple professional societies and mandated by the Center for Medicare and Medicaid Services since lung cancer screening has both benefits and risks. However, uptake of SDM counseling as well as lung cancer screening itself remain low. We sought to develop educational text messages about lung cancer screening as an innovative implementation intervention tool to promote patient-provider discussion about lung cancer screening. Methods: After the study team drafted educational text messages about lung cancer screening, informed by existing decision aids, participants who had had lung cancer screening were recruited and asked to review and edit text messages. After that, participants eligible for lung cancer screening without the previous screening experience were recruited and were asked to select the messages to be included in this text message intervention. The final set of 14 text messages were delivered to the participants both with and without the previous lung cancer screening over a period of 14 days. Participants completed a telephone survey assessing their reactions to the messages after receiving the last message. Results: We successfully involved twelve participants with lung cancer screening experience and eleven lung cancer screening eligible participants without previous screening experience in the development of educational text messages about lung cancer screening. After one participant withdrew, 22 participants received text messages and completed the survey regarding the messages. Most participants (18 of 22) reported reading all 14 text messages, however most recommended sending fewer messages (median recommended number of messages = 10). Participants found the educational text messages informative. Only four participants reported the text messages triggered anxiety and two reported text messages disrupted their daily activities. Participants perceived the text messages would empower patients to discuss lung cancer screening with their providers. Conclusion: Participants generally supported the use of educational text messages about lung cancer screening to increase patients’ awareness and promote patient-provider discussion. Engaging patients in the development and evaluation of text messages elicited helpful feedback that will inform the content of the messages to be delivered via this lung cancer screening text messages intervention.

Although Radio Frequency Identification (RFID) and Real-Time Location System (RTLS) technologies for inventory tracking have been growing in popularity, the healthcare industry has been reluctant to adopt these technologies. One of the primary reasons for this lack of enthusiasm has been the risk associated with electromagnetic interference between RFID/RTLS systems and medical equipment functionality. The other reason has been the substantial cost and complexity of implementing RFID/RTLS in healthcare organizations. In this study, we show that there are several ways to safely install RFID/RTLS systems to improve the inventory management processes of hospitals and clinics. We then analyze the inventory shrinkage (loss and theft) data of the Veterans Health Administration VISN 10 (the Veterans Integrated Service Network of Ohio) using a mathematical model to estimate the annual shrinkage. Finally, we develop an economic cost/benefit analysis database system in Microsoft Access that can be used to calculate the breakeven point of RFID/RTLS implementations, as well as calculate the expected reduction in inventory- related operating costs. This system can be adapted for cost/benefit analyses in similar inventory-intensive environments.

Inflammation is often a protective reaction against harmful foreign agents. However, in many disease conditions, the mechanisms behind the inflammatory response are poorly understood. Often times, the inflammation causes adverse effects, such as joint pain, abdominal pain, fever, fatigue, and loss of appetite. Thus, many treatments aim to inhibit the inflammatory response in order to control adverse symptoms. Such treatments include TNFα inhibitors. However, a major risk associated with drugs inhibiting tumor necrosis factor alpha (TNFα) is serious infection, including tuberculosis (TB). Anti-TNFα therapy is used to treat patients with Crohn’s disease, for which the risk of tuberculosis may be even more concerning. Recent literature suggests Crohn’s might involve Mycobacterium avium subspecies paratuberculosis (MAP), an intracellular TB-like bacterium. This study seeks to investigate the risk of developing TB in patients with Crohn’s disease treated with TNFα inhibitors. A meta-analysis synthesized existing evidence. Evidence came from published randomized, double-masked, placebo-controlled trials of TNFα inhibitors for treatment of adult Crohn’s disease. Twenty-three trials were identified, including 5,669 patients. The risk of tuberculosis was significantly increased in anti-TNFα treated patients, with a risk difference of 0.028 (95% confidence interval [CI], 0.0011-0.055). The odds ratio was 4.85 (95% CI, 1.02-22.99) when all studies were included and 5.85 (95% CI, 1.13-30.38) when studies reporting zero tuberculosis cases were excluded. The risk of tuberculosis is increased in patients with Crohn’s disease treated with TNFα inhibitors. The medical community should be alerted about this risk and the potential for TNFα inhibitor usage favoring granulomatous infections and worsening the patient condition.