Browsing by Author "Weiner, Michael"
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Item 4227 Closing the cross-institutional referral loop: Applying human factors to improve consultations(Cambridge University Press, 2020) Savoy, April; Weiner, Michael; Damush, Teresa; Medicine, School of MedicineOBJECTIVES/GOALS: Although referrals for specialty consultations are a core clinical process, they are prone to coordination and communication breakdowns that have led to adverse clinical outcomes. This project’s objective is to improve timely documentation, transmission, access, and quality of consultation notes across healthcare systems. METHODS/STUDY POPULATION: There are two specific aims for this project. In Aim 1, we will characterize clinical workflows and information flow during cross-institutional referrals. In Aim 2, we will develop and test a prototype leveraging electronic health information exchange (HIE) to increase closing the loop for cross-institutional referrals and improve the quality of consultation notes. To accomplish these aims, we will use human factors methods, including data analytics, medical-record reviews, semi-structured interviews of consultants, rapid prototyping, and usability evaluations. RESULTS/ANTICIPATED RESULTS: Results will inform the design and integration of clinician-facing technologies into clinical workflows to close the referral loop and improve diagnostic processes. Aim 1 will provide quantitative evidence about the quality of cross-institutional referrals, inform the eventual implementation of our prototype, and identify user interface features required for successful electronic health information exchange. Based on the results from Aim 1, reports and visual representations will be generated to illustrate information flows and clinical workflows. This will prioritize design efforts for the intervention’s prototype. Aim 2 will translate clinicians’ requirements into prototype features and assess clinicians’ experience with the prototype. DISCUSSION/SIGNIFICANCE OF IMPACT: The use and usefulness of HIE has been limited due to usability and implementation issues. Cross-institutional referrals are complex and dependent on HIE due to EHRs’ lack of interoperability. This project will provide evidence-based recommendations for the use of Fast Healthcare Interoperability Resources (FHIR) to improve HIE during referrals.Item 50048 Closing the cross-institutional referral loop: Assessment of consultation note quality(Cambridge University Press, 2021-03-30) Savoy, April; Sangani, Amee; Weiner, Michael; Medicine, School of MedicineIMPACT: Results will inform the design of health information technologies that assess and improve clinicians’ interpersonal communication supporting co-management of care across health institutions. OBJECTIVES/GOALS: Poor communication and co-management of comorbidities during the referral process increase physician workload, patient burden, and safety risks. In this preliminary study, our objective was to understand how consultants’ notes support physician collaboration within and across health care institutions. METHODS/STUDY POPULATION: We reviewed medical records. Accessing the Indiana Network for Patient Care database, consultation notes were randomly selected from four specialties: cardiothoracic surgery, neurology, rheumatology, and oncology. These specialties were identified, in advance, as challenging in interprofessional communication. The notes reviewed were associated with in-person consultations at a medical network in the Midwest from 2016 to 2019, including internal and cross-institutional (i.e., external) referrals. The Quality of Consult Assessment tool was adapted to assess note quality and co-management facilitation. Two researchers reviewed all records independently. A consensus meeting was then held to discuss and resolve discrepancies. RESULTS/ANTICIPATED RESULTS: Medical records of ten patients with comorbidities were reviewed. The mean age was 67 (SD= 12 years); one patient was a child. All consultation notes contained clinical recommendations. Seventy percent of notes referred to explicit consultant responsibilities. Conversely, only one contained explicit responsibilities for referrers. Medical records denoted reliance on support staff to send messages among referrers, consultants, and patients via phone calls and facsimile. The use of fax machines to send medical records to referrers was more prominent after cross-institutional consultations. DISCUSSION/SIGNIFICANCE OF FINDINGS: Clinical documentation supported specialty referrals for transitions of care rather than co-management of care. Accessing medical records across institutions contributed to a lack of clinical context, and workflow inefficiencies, when attempting to co-manage clinical care.Item Acceptance of use of personal health record: factors affecting physicians' perspective(2011-10-19) Agrawal, Ekta; Jones, Josette F.; Weiner, Michael; Simmermaker, JenniferAcceptance of PHR by physicians is fundamental as they play important role towards the promotion of PHR adoption by providing the access to the data to be maintained in PHR and also, using the information within the PHR for decision making. Therefore it is important to measure physicians' perspective on usefulness of PHR, and also the value and trust they have in PHR usage. Review of previous researches identifies the lack of availability of a valid survey instrument that can be used to measure physicians' perception on all different aspects of PHR use and acceptance. Using the integrated literature review methodology and Unified Theory of Acceptance and Use of Technology (UTAUT) as a guiding framework, this study was aimed to identify the factors that can be used in the development of comprehensive evaluation instrument to understand physicians' acceptance of PHR. Total 15 articles were selected for literature review and using the content analysis method, 189 undifferentiated data units were extracted from those articles. These data units were then categorized into the four core constructs of UTAUT. ―Other categorization system was also created for the data units that could not be classified into one of the UTAUT core constructs. Among four core UTAUT constructs, Performance Expectancy is found to be the most influential factor in physicians' acceptance of PHR, followed by ―Other factors, Facilitating Condition and Social Influence. Effort expectancy was found to be the least influential. The identified specific factors within each domain can be used to develop a valid survey instrument to measure physicians' perception on PHR.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 Advancing the Science of Electronic Health Record Transitions(Springer, 2023) Weiner, Michael; Rinne, Seppo T.; Haggstrom, David A.; Yano, Elizabeth M.; Medicine, School of MedicineItem Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation(Oxford University Press, 2014-10) Russ, Alissa L.; Zillich, Alan J.; Melton, Brittany L.; Russell, Scott A.; Chen, Siying; Spina, Jeffrey R.; Weiner, Michael; Johnson, Elizabette G.; Daggy, Joanne K.; McAnas, M. Sue; Hawsey, Jason M.; Puleo, Anthony G.; Doebbeling, Bradley N.; Saleem, Jason J.; Medicine Faculty Volunteers, IU School of MedicineOBJECTIVE: To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. MATERIALS AND METHODS: We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. RESULTS: Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024). DISCUSSION: Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. CONCLUSIONS: This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes.Item Autosomal dominant and sporadic late onset Alzheimer's disease share a common in vivo pathophysiology(Oxford University Press, 2022) Morris, John C.; Weiner, Michael; Xiong, Chengjie; Beckett, Laurel; Coble, Dean; Saito, Naomi; Aisen, Paul S.; Allegri, Ricardo; Benzinger, Tammie L. S.; Berman, Sarah B.; Cairns, Nigel J.; Carrillo, Maria C.; Chui, Helena C.; Chhatwal, Jasmeer P.; Cruchaga, Carlos; Fagan, Anne M.; Farlow, Martin; Fox, Nick C.; Ghetti, Bernardino; Goate, Alison M.; Gordon, Brian A.; Graff-Radford, Neill; Day, Gregory S.; Hassenstab, Jason; Ikeuchi, Takeshi; Jack, Clifford R.; Jagust, William J.; Jucker, Mathias; Levin, Johannes; Massoumzadeh, Parinaz; Masters, Colin L.; Martins, Ralph; McDade, Eric; Mori, Hiroshi; Noble, James M.; Petersen, Ronald C.; Ringman, John M.; Salloway, Stephen; Saykin, Andrew J.; Schofield, Peter R.; Shaw, Leslie M.; Toga, Arthur W.; Trojanowski, John Q.; Vöglein, Jonathan; Weninger, Stacie; Bateman, Randall J.; Buckles, Virginia D.; Dominantly Inherited Alzheimer Network; Alzheimer’s Disease Neuroimaging and Initiative; Neurology, School of MedicineThe extent to which the pathophysiology of autosomal dominant Alzheimer's disease corresponds to the pathophysiology of 'sporadic' late onset Alzheimer's disease is unknown, thus limiting the extrapolation of study findings and clinical trial results in autosomal dominant Alzheimer's disease to late onset Alzheimer's disease. We compared brain MRI and amyloid PET data, as well as CSF concentrations of amyloid-β42, amyloid-β40, tau and tau phosphorylated at position 181, in 292 carriers of pathogenic variants for Alzheimer's disease from the Dominantly Inherited Alzheimer Network, with corresponding data from 559 participants from the Alzheimer's Disease Neuroimaging Initiative. Imaging data and CSF samples were reprocessed as appropriate to guarantee uniform pipelines and assays. Data analyses yielded rates of change before and after symptomatic onset of Alzheimer's disease, allowing the alignment of the ∼30-year age difference between the cohorts on a clinically meaningful anchor point, namely the participant age at symptomatic onset. Biomarker profiles were similar for both autosomal dominant Alzheimer's disease and late onset Alzheimer's disease. Both groups demonstrated accelerated rates of decline in cognitive performance and in regional brain volume loss after symptomatic onset. Although amyloid burden accumulation as determined by PET was greater after symptomatic onset in autosomal dominant Alzheimer's disease than in late onset Alzheimer's disease participants, CSF assays of amyloid-β42, amyloid-β40, tau and p-tau181 were largely overlapping in both groups. Rates of change in cognitive performance and hippocampal volume loss after symptomatic onset were more aggressive for autosomal dominant Alzheimer's disease participants. These findings suggest a similar pathophysiology of autosomal dominant Alzheimer's disease and late onset Alzheimer's disease, supporting a shared pathobiological construct.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 Care Coordination Strategies and Barriers during Medication Safety Incidents: a Qualitative, Cognitive Task Analysis(Springer, 2021) Russ-Jara, Alissa L.; Luckhurst, Cherie L.; Dismore, Rachel A.; Arthur, Karen J.; Ifeachor, Amanda P.; Militello, Laura G.; Glassman, Peter A.; Zillich, Alan J.; Weiner, Michael; Medicine, School of MedicineBackground: Medication errors are prevalent in healthcare institutions worldwide, often arising from difficulties in care coordination among primary care providers, specialists, and pharmacists. Greater knowledge about care coordination surrounding medication safety incidents can inform efforts to improve patient safety. Objectives: To identify strategies that hospital and outpatient healthcare professionals (HCPs) use, and barriers encountered, when they coordinate care during a medication safety incident involving an adverse drug reaction, drug-drug interaction, or drug-renal concern. Design: We asked HCPs to complete a form whenever they encountered these incidents and intervened to prevent or mitigate patient harm. We stratified incidents across HCP roles and incident categories to conduct follow-up cognitive task analysis interviews with HCPs. Participants: We invited all physicians and pharmacists working in inpatient or outpatient care at a tertiary Veterans Affairs Medical Center. We examined 24 incidents: 12 from physicians and 12 from pharmacists, with a total of 8 incidents per category. Approach: Interviews were transcribed and analyzed via a two-stage inductive, qualitative analysis. In stage 1, we analyzed each incident to identify decision requirements. In stage 2, we analyzed results across incidents to identify emergent themes. Key results: Most incidents (19, 79%) were from outpatient care. HCPs relied on four main strategies to coordinate care: cognitive decentering; collaborative decision-making; back-up behaviors; and contingency planning. HCPs encountered four main barriers: role ambiguity and constraints, breakdowns (e.g., delays) in care, challenges related to the electronic health record, and factors that increased coordination complexity. Each strategy and barrier occurred across all incident categories and HCP groups. Pharmacists went to extra effort to ensure safety plans were implemented. Conclusions: Similar strategies and barriers were evident across HCP groups and incident types. Strategies for enhancing patient safety may be strengthened by deliberate organizational support. Some barriers could be addressed by improving work systems.Item Clinical thinking via electronic note templates: Who benefits?(Springer, 2021) Savoy, April; Frankel, Richard; Weiner, Michael