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Browsing by Author "Militello, Laura"
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Item Barriers to Single-Dose Intravesical Chemotherapy in Non-muscle Invasive Bladder Cancer: What's the Problem?(American Urological Association, 2020) Cary, Clint; Militello, Laura; DeChant, Paige; Frankel, Richard; Koch, Michael O.; Weiner, Michael; Urology, School of MedicineIntroduction: The intravesical instillation of mitomycin C immediately following surgery for non-muscle invasive bladder cancer has been shown to be efficacious in reducing cancer recurrence. As a result, the American Urological Association adopted guidelines for non-muscle invasive bladder cancer care to support its use in low to intermediate risk patients. Despite this, urologists' use of this drug following transurethral resection of a bladder tumor (TURBT) has been reported as low as 5% or less. Our study objective was to better understand the barriers urologists experience in using mitomycin C. Methods: Semi-structured interviews were conducted with 13 practicing urologists at 4 geographically distinct practice locations throughout Indiana between 2017 and 2018. Cognitive task analysis was used to explore factors that influenced their clinician decision-making about Mitomycin C use following TURBT in specific patient cases. Interview transcripts were coded and analyzed using immersion/crystallization to identify emergent themes. Results: The median age of the urologists interviewed was 44 (IQR 40-48). Eighty-five percent were male. Approximately 30% had completed urologic fellowship training; 62% were in private practice. Three major themes related to the use of mitomycin C emerged: cumbersome workflow processes, urologists' fears of side effects, and issues of identifying patients most likely to benefit. Conclusion: Workflow, fear, and value are key factors and also represent complexities of translating efficacy into effectiveness for a drug with known benefits to patients. Areas of potential intervention development to improve the use of mitomycin C to reduce recurrence of bladder cancer are suggested. Alternatives such as gemcitabine may also help overcome these barriers.Item Cognitive requirements for primary care providers during the referral process: Information needed from and interactions with an electronic health record system(Elsevier, 2019-09) Savoy, April; Militello, Laura; Diiulio, Julie; Midboe, Amanda M.; Weiner, Michael; Abbaszadegan, Hamed; Herout, Jennifer; Computer and Information Science, School of ScienceObjectives This study sought to identify and describe the cognitive requirements and associated information needs of referring primary care providers (PCPs) during the referral process as well as characterize referring PCPs’ experiences with current health information technology. Materials and methods We interviewed 62 referring PCPs. Our four-member analysis team used hierarchical task analysis to construct a goal-directed hierarchy. We utilized extensions of the task analysis to describe PCPs’ common experiences with health information technologies throughout the referral process. Results The resultant goal hierarchy includes one main goal (Referral for Additional Care), two sub-goals (Assess Patient’s Condition and Manage Referrals), and four major tasks with respective decisions (What consultation is warranted; What information should I provide; What additional action is needed; and How to integrate specialists’ findings). Approximately 22 information needs were commonly identified and PCPs described their use of various sources - other PCPs, electronic health records, chat software, and paper- to satisfy those information needs. Conclusion Cognitive demand for referring PCPs is high throughout the referral process. They have to search, identify, compose, track, and integrate information across multiple screens, systems, and people. Existing interfaces do not adequately support the communication, information exchange, or care coordination related to the referral process. Results from this study provide an important foundation for developing patient-centered displays that support PCPs’ decision-making process and reduce cognitive challenges.Item How opioid prescribing policies influence primary care clinicians' treatment decisions and conversations with patients with chronic pain(Weston Medical, 2021) Danielson, Elizabeth C.; Harle, Christopher A.; Downs, Sarah M.; Militello, Laura; Mazurenko, Olena; Health Policy and Management, School of Public HealthObjective: The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain aimed to assist primary care clinicians in safely and effectively prescribing opioids for chronic noncancer pain. Individual states, payers, and health systems issued similar policies imposing various regulations around opioid prescribing for patients with chronic pain. Experts argued that healthcare organizations and clinicians may be misapplying the federal guideline and subsequent opioid prescribing policies, leading to an inadequate pain management. The objective of this study was to understand how primary care clinicians involve opioid prescribing policies in their treatment decisions and in their conversations with patients with chronic pain. Design: We conducted a secondary qualitative analysis of data from 64 unique primary care visits and 87 post-visit interviews across 20 clinicians from three healthcare systems in the Midwestern United States. Using a multistep process and thematic analysis, we systematically analyzed data excerpts addressing opioid prescribing policies. Results: Opioid prescribing policies influenced clinicians' treatment decisions to not initiate opioids, prescribe fewer opioids overall (theme #1), and begin tapering and discontinuation of opioids (theme #2) for most patients with chronic pain. Clinical precautions, described in the opioid prescribing policies to monitor use, were directly invoked during visits for patients with chronic pain (theme #3). Conclusions: Opioid prescribing policies have multidimensional influence on clinician treatment decisions for patients with chronic pain. Our findings may inform future studies to explore mechanisms for aligning pressures around opioid prescribing, stemming from various opioid prescribing policies, with the need to deliver individualized pain care.Item Integrating Clinical Decision Support into Workflow(2011) Doebbeling, Bradley N.; Saleem, Jason; Haggstrom, David; Militello, Laura; Flanagan, Mindy; Arbuckle, Nicole; Kiess, Chris; Hoke, Shawn; Dexter, Paul; Linder, Jeff; Sarbah, Steedman; Burgo, LucillePurpose: The aims were to (1) identify barriers and facilitators related to integration of clinical decision support (CDS) into workflow and (2) develop and test CDS design alternatives. Scope: To better understand CDS integration, we studied its use in practice, focusing on CDS for colorectal cancer (CRC) screening and followup. Phase 1 involved outpatient clinics of four different systems—120 clinic staff and providers and 118 patients were observed. In Phase 2, prototyped design enhancements to the Veterans Administration’s CRC screening reminder were compared against its current reminder in a simulation experiment. Twelve providers participated. Methods: Phase 1 was a qualitative project, using key informant interviews, direct observation, opportunistic interviews, and focus groups. All data were analyzed using a coding template, based on the sociotechnical systems theory, which was modified as coding proceeded and themes emerged. Phase 2 consisted of rapid prototyping of CDS design alternatives based on Phase 1 findings and a simulation experiment to test these design changes in a within-subject comparison. Results: Very different CDS types existed across sites, yet there are common barriers: (1) lack of coordination of “outside” results and between primary and specialty care; (2) suboptimal data organization and presentation; (3) needed provider and patient education; (4) needed interface flexibility; (5) needed technological enhancements; (6) unclear role assignments; (7) organizational issues; and (8) disconnect with quality reporting. Design enhancements positively impacted usability and workflow integration but not workload. Conclusions: Effective CDS design and integration requires: (1) organizational and workflow integration; (2) integrating outside results; (3) improving data organization and presentation in a flexible interface; and (4) providing just-in time education, cognitive support, and quality reporting.