Browsing by Author "Lee, Joy L."
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Item Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs(Springer Nature, 2024-07-18) Weiner, Michael; Flanagan, Mindy E.; Ernst, Katie; Cottingham, Ann H.; Rattray, Nicholas A.; Franks, Zamal; Savoy, April W.; Lee, Joy L.; Frankel, Richard M.; Medicine, School of MedicineBackground: Electronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality. Methods: Patients and primary care clinicians across five midwestern primary care clinics of the US Department of Veterans Affairs were recruited into a prospective observational study. Clinical encounters were video-recorded and transcribed verbatim. Using the Physician Documentation Quality Instrument (PDQI-9) added to other measures, reviewers scored quality of the documentation by comparing transcripts to corresponding encounter notes. PDQI-9 items were scored from 1 to 5, with higher scores indicating higher quality. Results: Encounters (N = 49) among 11 clinicians were analyzed. Most issues that patients initiated in discussion were omitted from notes, and nearly half of notes referred to information or observations that could not be verified. Four notes lacked concluding assessments and plans; nine lacked information about when patients should return. Except for thoroughness, PDQI-9 items that were assessed achieved quality scores exceeding 4 of 5 points. Conclusions: Among outpatient primary care electronic records examined, most issues that patients initiated in discussion were absent from notes, and nearly half of notes referred to information or observations absent from transcripts. EHRs may contribute to certain kinds of errors. Approaches to improving documentation should consider the roles of the EHR, patient, and clinician together.Item Asynchronous Conferencing Through a Secure Messaging Application Increases Reporting of Medical Errors in a Mature Trauma Center(Sage, 2023) Lee, Joy L.; Isenberg, Scott; Adams, Georgann; Thurston, Maria; Hammer, Peter M.; Mohanty, Sanjay K.; Jenkins, Peter C.; Surgery, School of MedicineBackground: Medical errors occur frequently, yet they are often under-reported and strategies to increase the reporting of medical errors are lacking. In this work, we detail how a level 1 trauma center used a secure messaging application to track medical errors and enhance its quality improvement initiatives. Methods: We describe the formulation, implementation, evolution, and evaluation of a chatroom integrated into a secure texting system to identify performance improvement and patient safety (PIPS) concerns. For evaluation, we used descriptive statistics to examine PIPS reporting by the reporting method over time, the incidence of mortality and unplanned ICU readmissions tracked in the hospital trauma registry over the same, and time-to-loop closure over the study period to quantify the impact of the processes instituted by the PIPS team. We also categorized themes of reported events. Results: With the implementation of a PIPS chatroom, the number of events reported each month increased and texting became the predominant way for users to report trauma PIPS events. This increase in PIPS reporting did not appear to be accompanied by an increase in mortality and unplanned ICU readmissions. The PIPS team also improved the tracking and timely resolution of PIPS events and observed a decrease in time-to-loop closure with the implementation of the PIPS chatroom. Conclusions: The adoption of clinical texting as a way to report PIPS events was associated with increased reporting of such events and more timely resolution of concerns regarding patient safety and healthcare quality.Item Content Analysis of Emoji and Emoticon Use in Clinical Texting Systems(American Medical Association, 2023-06-01) Halverson, Colin M. E.; Donnelly, Claire E.; Weiner, Michael; Lee, Joy L.; Medicine, School of MedicineImportance: Emoji and emoticons are quickly becoming an omnipresent feature of virtual communication. As health care systems increasingly adopt clinical texting applications, it is critical to understand how clinicians use these ideograms with colleagues and how it may affect their interactions. Objective: To evaluate the functions that emoji and emoticons serve in clinical text messages. Design, setting, and participants: This qualitative study's content analysis of clinical text messages from a secure clinical messaging platform was conducted to assess the communicative function of emoji and emoticons. The analysis included messages sent by hospitalists to other health care clinicians. A subset of a random 1% sample of all message threads, which included at least 1 emoji or emoticon, on a clinical texting system used by a large, Midwestern US hospital from July 2020 until March 2021 were analyzed. A total of 80 hospitalists participated in the candidate threads. Main outcomes: Whether and what kind of emoji or emoticon was deployed in each reviewed thread was tabulated by the study team. The communicative function of each emoji and emoticon was assessed according to a prespecified coding scheme. Results: A total of 80 hospitalists (49 [61%] male; 30 [37%] Asian, 5 [6%] Black or African American, 2 [3%] Hispanic or Latinx, 42 [53%] White; of 41 with age data, 13 [32%] aged 25-34 years, 19 [46%] aged 35-44 years) participated in the 1319 candidate threads. Within the sample of 1319 threads, 7% of threads (155 unique messages) contained at least 1 emoji or emoticon. The majority (94 [61%]) functioned emotively, that is, conveyed the internal state of the sender, and 49 (32%) served to open, maintain, or close communication. No evidence was identified that they caused confusion or were seen as inappropriate. Conclusions and relevance: This qualitative study found that when clinicians use emoji and emoticons in secure clinical texting systems, these symbols function primarily to convey new and interactionally salient information. These results suggest that concerns about the professionalism of emoji and emoticon use may be unwarranted.Item A critical appraisal of guidelines for electronic communication between patients and clinicians: the need to modernize current recommendations(Oxford, 2018-04) Lee, Joy L.; Matthias, Marianne S.; Menachemi, Nir; Frankel, Richard M.; Weiner, Michael; Medicine, School of MedicineBackground Patient-provider electronic communication has proliferated in recent years, yet there is a dearth of published research either leading to, or including, recommendations that improve clinical care and prevent unintended negative consequences. We critically appraise published guidelines and suggest an agenda for future work in this area. Objective To understand how existing guidelines align with current practice, evidence, and technology. Methods We performed a narrative review of provider-targeted guidelines for electronic communication between patients and providers, searching Ovid MEDLINE, Embase, and PubMed databases using relevant terms. We limited the search to articles published in English, and manually searched the citations of relevant articles. For each article, we identified and evaluated the suggested practices. Results Across 11 identified guidelines, the primary focus was on technical and administrative concerns, rather than on relational communication. Some of the security practices recommended by the guidelines are no longer needed because of shifts in technology. It is unclear the extent to which the recommendations that are still relevant are being followed. Moreover, there is no guideline-cited evidence of the effectiveness of the practices that have been proposed. Conclusion Our analysis revealed major weaknesses in current guidelines for electronic communication between patients and providers: the guidelines appear to be based on minimal evidence and offer little guidance on how best to use electronic tools to communicate effectively. Further work is needed to systematically evaluate and identify effective practices, create a framework to evaluate quality of communication, and assess the relationship between electronic communication and quality of care.Item Financial hardship is associated with lower uptake of colorectal, breast, and cervical cancer screenings(Springer, 2021-10) Kasting, Monica L.; Haggstrom, David A.; Lee, Joy L.; Dickinson, Stephanie L.; Shields, Cleveland G.; Rawl, Susan M.; School of NursingPURPOSE: Cancer screening uptake differs between groups in ways that cannot be explained by socioeconomic status alone. This study examined associations between material, psychosocial, and behavioral aspects of financial hardship and cancer screening behaviors. METHODS: Surveys were mailed to 7,979 people ages 18-75 who were seen in the statewide health system in Indiana. Participants reported SES, feelings about finances, and whether they had to forgo medical care due to cost. This was compared to uptake of mammogram, colonoscopy/sigmoidoscopy, and Pap testing in best-fit multivariable logistic regression analyses controlling for demographic and healthcare characteristics. RESULTS: A total of 970 surveys were returned; the majority of respondents were female (54%), non-Hispanic White (75%), and over 50 years old (76%). 15% reported forgoing medical care due to cost; this barrier was higher among Black than White participants (24% vs. 13%; p = 0.001). In a best fit regression model for colonoscopy/sigmoidoscopy, those who reported they had to forgo medical care due to cost had lower odds of screening (aOR 0.41; 95% CI 0.22-0.74). Forgoing medical care due to cost was not significantly associated with Pap testing in bivariate analyses. For mammogram, forgoing medical care due to cost was significant in bivariate analyses (OR 0.44; 95% CI 0.22-0.88), but was not significant in the multivariable model. CONCLUSION: Associations between financial hardship and cancer screening suggest the need to reduce barriers to cancer screening even among patients who have access to healthcare. Future research should explore barriers related to both healthcare and personal costs.Item “I Don’t Want to Spend the Rest of my Life Only Going to a Gender Wellness Clinic”: Healthcare Experiences of Patients of a Comprehensive Transgender Clinic(Springer, 2022-10) Lee, Joy L.; Huffman, Monica; Rattray, Nicholas A.; Carnahan, Jennifer L.; Fortenberry, J. Dennis; Fogel, Janine M.; Weiner, Michael; Matthias, Marianne S.; Medicine, School of MedicineBackground Transgender individuals are less likely to have had a primary care visit in the last year than cisgender individuals. While the importance of multidisciplinary clinics for transgender care has been established, little is known about the healthcare experiences of transgender patients with these clinics. Objective To describe how patients experience transgender clinics and how these experiences compare to those experiences in other settings. Participants Twenty-one adult patients of a gender health program. Design and Approach Semi-structured interviews of transgender patients. The interviews focused on two domains: healthcare experiences and relationships with healthcare providers. Key Results Overall, transgender patients expressed a need for healthcare services, particularly for primary care, that are partially met by the comprehensive care clinic model. Limitations in access included the lack of willing providers, where the patients live, and long wait times for appointments. Participants recounted a range of experiences, both positive and negative, with providers outside of the transgender clinic, but only positive experiences to share about providers from the transgender clinic. Conclusion Outside specialty transgender settings, many patients had negative experiences with providers who were unwilling or unable to provide care. This study speaks to the need for primary care providers who can and will treat transgender patients, as well as the need for healthcare spaces that feel safe to transgender patents. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-022-07408-5.Item Insecure messaging: how clinicians approach potentially problematic messages from patients(Oxford University Press, 2020-12-05) Lee, Joy L.; Matthias, Marianne S.; Huffman, Monica; Frankel, Richard M.; Weiner, Michael; Medicine, School of MedicineObjective: Secure messaging has become an integrated function of patient portals, but misuse of secure messaging by both patients and clinicians can lead to miscommunication and errors, such as overlooked urgent messages. We sought to uncover variations in clinician approaches and responses to messaging with patients. Methods: In this two-part study, 20 primary care clinicians (1) composed message responses to five hypothetical patient vignettes and messages and (2) were subsequently interviewed for their perspectives on appropriate circumstances for secure messaging. Messages and interviews were analyzed for themes. Results: Clinicians have different experiences with, and perceptions of, secure messaging. The messages the clinicians wrote were uniformly respectful, but differed in degrees of patient-centeredness and level of detail. None of the clinicians found their messaging workload to be unmanageable. From the interviews, we found divergent clinician perspectives about when to use secure messaging and how to respond to emotional content. Conclusion: Clinicians have different opinions about the appropriateness of secure messaging in response to specific medical issues. Our results noted a desire and need for greater guidance about secure messaging. This aspect of informatics education warrants greater attention in clinical practice. Practical implications: We summarize the types of issues raised by the participants yet to be addressed by existing guidelines. Further guidance from hospitals, professional societies, and other institutions that govern clinician behavior on the appropriateness and effectiveness of delivering care through secure messaging may aid clinicians and patients.Item Qualitative Analysis of Team Communication with a Clinical Texting System at a Midwestern Academic Hospital(Thieme, 2022) Lee, Joy L.; Kara, Areeba; Huffman, Monica; Matthias, Marianne S.; Radecki, Bethany; Savoy, April; Schaffer, Jason T.; Weiner, Michael; Medicine, School of MedicineBackground: Hospitals are increasingly replacing pagers with clinical texting systems that allow users to use smartphones to send messages while maintaining compliance for privacy and security. As more institutions adopt such systems, the need to understand the impact of such transitions on team communication becomes ever more significant. Methods: We conducted focus groups with hospitalists and individual interviews with nurses at one academic medical center in the Midwest. All interviews and focus groups were audiorecorded, transcribed, and deidentified for analysis. All transcripts and notes were independently read by two members of the research team and coded for themes. Results: Twenty-one hospitalists and eight nurses participated in the study. Although study participants spoke favorably of texting, they identified more dissatisfactions with texting than benefits. There were disagreements regarding appropriate texting practices both within and between the hospitalists and nurses. Conclusion: Despite the benefits of texting, there is room for improving team communication and understanding in the realm of clinical texting. A lack of shared understanding regarding when and how to use texting may require long-term solutions that address teamwork and appropriateness.Item Racial and Socioeconomic Disparities in Cancer-Related Knowledge, Beliefs, and Behaviors in Indiana(AACR, 2019-03) Rawl, Susan M.; Dickinson, Stephanie; Lee, Joy L.; Roberts, Jamie L.; Teal, Evgenia; Baker, Layla B.; Kianersi, Sina; Haggstrom, David A.; School of NursingBackground: This statewide survey examined differences in cancer-related knowledge, beliefs, and behaviors between racial and socioeconomic groups in select counties in Indiana. Methods: A stratified random sample of 7,979 people aged 18–75 who lived in one of 34 Indiana counties with higher cancer mortality rates than the state average, and were seen at least once in the past year in a statewide health system were mailed surveys. Results: Completed surveys were returned by 970 participants, yielding a 12% response rate. Black respondents were less likely to perceive they were at risk for cancer and less worried about getting cancer. Individuals most likely to perceive that they were unlikely to get cancer were more often black, with low incomes (less than $20,000) or high incomes ($50,000 or more), or less than a high school degree. Black women were greater than six times more likely to be adherent to cervical cancer screening. Higher income was associated with receiving a sigmoidoscopy in the last 5 years and a lung scan in the past year. Those with the highest incomes were more likely to engage in physical activity. Both income and education were inversely related to smoking. Conclusions: Socioeconomic and racial disparities were observed in health behaviors and receipt of cancer screening. Black individuals had less worry about cancer. Impact: Understanding populations for whom cancer disparities exist and geographic areas where the cancer burden is disproportionately high is essential to decision-making about research priorities and the use of public health resources.Item Retention, Fasting Patterns, and Weight Loss With an Intermittent Fasting App: Large-Scale, 52-Week Observational Study(JMIR Publications, 2022-10-04) Torres, Luisa; Lee, Joy L.; Park, Seho; Di Lorenzo, R. Christian; Branam, Jonathan P.; Fraser, Shelagh A.; Salisbury, Benjamin A.; Health Policy and Management, School of Public HealthBackground: Intermittent fasting (IF) is an increasingly popular approach to dietary control that focuses on the timing of eating rather than the quantity and content of caloric intake. IF practitioners typically seek to improve their weight and other health factors. Millions of practitioners have turned to purpose-built mobile apps to help them track and adhere to their fasts and monitor changes in their weight and other biometrics. Objective: This study aimed to quantify user retention, fasting patterns, and weight loss by users of 2 IF mobile apps. We also sought to describe and model starting BMI, amount of fasting, frequency of weight tracking, and other demographics as correlates of retention and weight change. Methods: We assembled height, weight, fasting, and demographic data of adult users (ages 18-100 years) of the LIFE Fasting Tracker and LIFE Extend apps from 2018 to 2020. Retention for up to 52 weeks was quantified based on recorded fasts and correlated with user demographics. Users who provided height and at least 2 readings of weight and whose first fast and weight records were contemporaneous were included in the weight loss analysis. Fasting was quantified as extended fasting hours (EFH; hours beyond 12 in a fast) averaged per day (EFH per day). Retention was modeled using a Cox proportional hazards regression. Weight loss was analyzed using linear regression. Results: A total of 792,692 users were followed for retention based on 26 million recorded fasts. Of these, 132,775 (16.7%) users were retained at 13 weeks, 54,881 (6.9%) at 26 weeks, and 16,478 (2.1%) at 52 weeks, allowing 4 consecutive weeks of inactivity. The survival analysis using Cox regression indicated that retention was positively associated with age and exercise and negatively associated with stress and smoking. Weight loss in the qualifying cohort (n=161,346) was strongly correlated with starting BMI and EFH per day, which displayed a positive interaction. Users with a BMI ≥40 kg/m2 lost 13.9% of their starting weight by 52 weeks versus a slight weight gain on average for users with starting BMI <23 kg/m2. EFH per day was an approximately linear predictor of weight loss. By week 26, users lost over 1% of their starting weight per EFH per day on average. The regression analysis using all variables was highly predictive of weight change at 26 weeks (R2=0.334) with starting BMI and EFH per day as the most significant predictors. Conclusions: IF with LIFE mobile apps appears to be a sustainable approach to weight reduction in the overweight and obese population. Healthy weight and underweight individuals do not lose much weight on average, even with extensive fasting. Users who are obese lose substantial weight over time, with more weight loss in those who fast more.