Brad Doebbeling

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https://hdl.handle.net/1805/6678

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VizCom: A Novel Workflow Model for ICU Clinical Decision-Support
(2014-04) Faiola, Anthony; Srinivas, Preethi; Karanam, Yamini; Chartash, David; Doebbeling, Bradley N.
The Intensive Care Unit (ICU) has the highest annual mortality rate (4.4M) of any hospital unit or 25% of all clinical admissions. Studies show a relationship between clinician cognitive load and workflow, and their impact on patient safety and the subsequent occurrence of medical mishaps due to diagnostic error - in spite of advances in health information technology, e.g., bedside and clinical decision support (CDS) systems. The aim of our research is to: 1) investigate the root causes (underlying mechanisms) of ICU error related to the effects of clinical workflow: medical cognition, team communication/collaboration, and the use of diagnostic/CDS systems and 2) construct and validate a novel workflow model that supports improved clinical workflow, with goals to decrease adverse events, increase safety, and reduce intensivist time, effort, and cognitive resources. Lastly, our long-term objective is to apply data from aims one and two to design the next generation of diagnostic visualization-communication (VizCom) system that improves intensive care workflow, communication, and effectiveness in healthcare.
A regional informatics platform for coordinated antibiotic resistant infection tracking, alerting and prevention
(2013-04) Kho, Abel N.; Doebbeling, Bradley N.; Cashy, John P.; Rosenman, Marc B.; Dexter, Paul R.; Shepherd, David C.; Lemmon, Larry; Teal, Evgenia; Khokar, Shahid; Overhage, J. Marc
Background. We developed and assessed the impact of a patient registry and electronic admission notification system relating to regional antimicrobial resistance (AMR) on regional AMR infection rates over time. We conducted an observational cohort study of all patients identified as infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococci (VRE) on at least 1 occasion by any of 5 healthcare systems between 2003 and 2010. The 5 healthcare systems included 17 hospitals and associated clinics in the Indianapolis, Indiana, region. Methods. We developed and standardized a registry of MRSA and VRE patients and created Web forms that infection preventionists (IPs) used to maintain the lists. We sent e-mail alerts to IPs whenever a patient previously infected or colonized with MRSA or VRE registered for admission to a study hospital from June 2007 through June 2010. Results. Over a 3-year period, we delivered 12 748 e-mail alerts on 6270 unique patients to 24 IPs covering 17 hospitals. One in 5 (22%–23%) of all admission alerts was based on data from a healthcare system that was different from the admitting hospital; a few hospitals accounted for most of this crossover among facilities and systems. Conclusions. Regional patient registries identify an important patient cohort with relevant prior antibiotic-resistant infection data from different healthcare institutions. Regional registries can identify trends and interinstitutional movement not otherwise apparent from single institution data. Importantly, electronic alerts can notify of the need to isolate early and to institute other measures to prevent transmission.
Computerised Clinical Reminders Use in an Integrated Healthcare System
(2009) Fung, Constance; Tsai, Jerry; Lulejian, Armine; Glassman, Peter; Patterson, Emily; Doebbeling, Bradley N.; Asch, Steven
Objective: To examine levels of routine computerised clinical reminder use in a nationwide sample of primary care physicians and to identify factors influencing reminder use. Design: Cross-sectional using a self-administered questionnaire. Setting: The United States Veterans Health Administration. Methods: Survey responses from 461 VHA primary care physicians sampled from across the Veterans Health Administration were sampled and analysed. We asked physicians how many computerised clinical reminders they use per patient per visit and when they typically use computerised clinical reminders in their clinics. Measured physician characteristics included age, gender, year of medical degree, number of days in clinic per week, and attitudes towards computerised clinical reminders (measured on Likert-like scales). We used multivariable linear regression to determine factors associated with greater use of computerised clinical reminders per patient per visit. Results: Average computerised clinical reminder use per patient visit was 4.2 (SD = 2.5). Eightysix percent of physicians resolve reminders during the visit. In a multivariable regression model, a higher score on the team factors scale is associated with use of more reminders (increase of 0.24 reminders for each unit increase on the team factors scale, or one extra reminder for each four unit increase in the team factor scale). Working more days in clinic is associated with use of more reminders per patient visit (increase of 0.13 reminders for each extra half-day of clinic per week, or about one additional reminder for physicians working ten half-days per week versus physicians working two half-days per week). Academic facility affiliation is associated with one less reminder used per patient visit as compared with no affiliation. Conclusions: Most United States Veterans Health Administration primary care physicians use computerised clinical reminders, typically during the patient visit. Strategies to increase reminder use should focus on improving physicians’ understanding of their role in completing reminder-related tasks and improving usability for users such as physicians who work in clinic less frequently.
Development of a Workflow Integration Survey (WIS) for Implementing Computerized Clinical Decision Support
(2011-10) Flanagan, Mindy; Arbuckle, Nicole; Saleem, Jason J.; Militello, Laura G.; Haggstrom, David A.; Doebbeling, Bradley N.
Interventions that focus on improving computerized clinical decision support (CDS) demonstrate that successful workflow integration can increase the adoption and use of CDS. However, metrics for assessing workflow integration in clinical settings are not well established. The goal of this study was to develop and validate a survey to assess the extent to which CDS is integrated into workflow. Qualitative data on CDS design, usability, and integration from four sites was collected by direct observation, interviews, and focus groups. Thematic analysis based on the sociotechnical systems theory revealed consistent themes across sites. Themes related to workflow integration included navigation, functionality, usability, and workload. Based on these themes, a brief 12-item scale to assess workflow integration was developed, refined, and validated with providers in a simulation study. To our knowledge, this is one of the first tools developed to specifically measure workflow integration of CDS.
Efficiency Strategies for Facilitating Computerized Clinical Documentation in Ambulatory Care
(2013) Saleem, Jason J.; Adams, Stephanie; Frankel, Richard M.; Doebbeling, Bradley N.; Patterson, Emily S.
Most providers have experienced increased documentation demands with the use of electronic health records (EHRs). We sought to identify efficiency strategies that providers use to complete clinical documentation tasks in ambulatory care. Two observers performed ethnographic observations and interviews with 22 ambulatory care providers in a U.S. Veterans Affairs Medical Center. Observation notes and interview transcripts were coded for recurrent strategies relating to completion of the EHR progress notes. Findings included: the use of paper artifacts for handwritten notations; electronic templates for automation of certain parts of the note; use of shorthand and phrases rather than narrative writing; copying and pasting from previous EHR notes; directly entering information into the EHR note during the patient encounter; reliance on memory; and pre-populating an EHR note prior to seeing the patient. We discuss the findings in the context of distributed cognition to understand how clinical information is propagated and represented toward completion of a progress note. The study findings have important implications for improving and streamlining clinical documentation related to human factors workload management strategies.
Examining the Relationship between Clinical Decision Support and Performance Measurement
(2009-11) Haggstrom, David A.; Militello, Laura G.; Arbuckle, Nicole; Flanagan, Mindy; Doebbeling, Bradley N.
In concept and practice, clinical decision support (CDS) and performance measurement represent distinct approaches to organizational change, yet these two organizational processes are interrelated. We set out to better understand how the relationship between the two is perceived, as well as how they jointly influence clinical practice. To understand the use of CDS at benchmark institutions, we conducted semistructured interviews with key managers, information technology personnel, and clinical leaders during a qualitative field study. Improved performance was frequently cited as a rationale for the use of clinical reminders. Pay-for-performance efforts also appeared to provide motivation for the use of clinical reminders. Shared performance measures were associated with shared clinical reminders. The close link between clinical reminders and performance measurement causes these tools to have many of the same implementation challenges.
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, Lucille
Purpose: 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.
Multihospital Infection Prevention Collaborative: Informatics Challenges and Strategies to Prevent MRSA
(2013-11) Doebbeling, Bradley N.; Flanagan, Mindy E.; Nall, Glenna; Hoke, Shawn; Rosenman, Marc; Kho, Abel
We formed a collaborative to spread effective MRSA prevention strategies. We conducted a two-phase, multisite, quasi-experimental study of seven hospital systems (11 hospitals) in IN, MT, ME and Ontario, Canada over six years. Patients with prior MRSA were identified at admission using regional health information exchange data. We developed a system to return an alert message indicating a prior history of MRSA, directed to infection preventionists and admissions. Alerts indicated the prior anatomic site, and the originating institution. The combined approach of training and coaching, implementation of MRSA registries, notifying hospitals on admission of previously infected or colonized patients, and change strategies was effective in reducing MRSA infections over 80%. Further research and development of electronic surveillance tools is needed to better integrate the varied data source and support preventing MRSA infections. Our study supports the importance of hospitals collaborating to share data and implement effective strategies to prevent MRSA.
OpenMRS, A Global Medical Records System Collaborative: Factors Influencing Successful Implementation
(2011-10) Mohammed-Rajput, Nareesa A.; Smith, Dawn C.; Mamlin, Burke; Biondich, Paul; Doebbeling, Bradley N.
OpenMRS is an open-source, robust electronic health record (EHR) platform that is supported by a large global network and used in over forty countries. We explored what factors lead to successful implementation of OpenMRS in resource constrained settings. Data sources included in-person and telephone key informant interviews, focus groups and responses to an electronic survey from 10 sites in 7 countries. Qualitative data was coded through independent coding, discussion and consensus. The most common perceived benefits of implementation were for providing clinical care, reporting to funders, managing operations and research. Successful implementation factors include securing adequate infrastructure, and sociotechnical system factors, particularly adequate staffing, computers, and ability to use software. Strategic and tactical planning were successful strategies, including understanding and addressing the infrastructure and human costs involved, training or hiring personnel technically capable of modifying the software and integrating it into the daily work flow to meet clinicians’ needs.
Optimizing Perioperative Decision Making: Improved Information for Clinical Workflow Planning
(2012-11) Doebbeling, Bradley N.; Burton, Matthew M.; Wiebke, Eric A.; Miller, Spencer; Baxter, Laurence; Miller, Donald; Alvarez, Jorge; Pekny, Joseph
Perioperative care is complex and involves multiple interconnected subsystems. Delayed starts, prolonged cases and overtime are common. Surgical procedures account for 40–70% of hospital revenues and 30–40% of total costs. Most planning and scheduling in healthcare is done without modern planning tools, which have potential for improving access by assisting in operations planning support. We identified key planning scenarios of interest to perioperative leaders, in order to examine the feasibility of applying combinatorial optimization software solving some of those planning issues in the operative setting. Perioperative leaders desire a broad range of tools for planning and assessing alternate solutions. Our modeled solutions generated feasible solutions that varied as expected, based on resource and policy assumptions and found better utilization of scarce resources. Combinatorial optimization modeling can effectively evaluate alternatives to support key decisions for planning clinical workflow and improving care efficiency and satisfaction.

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