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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 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 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 Evaluation of Consultation Notes Within and Across Institutions: A Preliminary Study(Indiana University Medical Student Program for Research and Scholarship, 2020) Sangani, Amee; Savoy, April; Medicine, School of MedicineBackground/Objective: Patients with multiple chronic conditions require specialty consultations both within and across institutions for effective co-management of comorbidities. Poor communication during the referral process increases physician workload, patient burden and risks. Successful co-management relies on bi-directional information flow that supports interpersonal communication and establishment of clear tasks and responsibilities among physicians. However, flow of health information is often limited to specific health network access, phone calls, or faxes. Interpersonal communication is dependent on limited encounter notes. In this preliminary study, our objective was to understand how consultants’ notes support physician collaboration within and across health care institutions. Project Methods: To assess consultants’ notes, outpatient charts were randomly selected from the Indiana Network for Patient Care database representing consultations with five different specialties within the IU Health network, including referrals from within and outside of IU Health. The Quality of Consult Assessment tool was adapted to assess content of notes, emphasizing clinical recommendations, distribution of tasks and responsibilities, and communication plans. Results: Our sample included ten charts for patients who had comorbidities. All notes contained clinical recommendations that included an assessment and plan. 70% of notes contained explicit responsibilities of the consultants. Conversely, only one contained explicit responsibilities for referrers. Charts denoted reliance on support staff to send messages between referrers, consultants, and patients via phone and fax. Phone calls and faxes were more prominent in referrals across institutions. Conclusion and Impact: Our preliminary findings indicate that current clinical documentation supports specialty referrals for transitions of care rather than co-management of care. Difficulties in accessing patient charts across institutions leads to a lack of clinical context and workflow inefficiencies when attempting to co-manage care. These findings demonstrate negative implications in health outcomes for patients with multiple comorbidities that require more care coordination within and across institutions.Item The care planning umbrella: The evolution of advance care planning(Wiley, 2023) Hickman, Susan E.; Lum, Hillary D.; Walling, Anne M.; Savoy, April; Sudore, Rebecca L.; School of NursingItem Continuous Glucose Monitoring Workflows for Elderly, Cognitively Impaired Adults with Type 2 Dia(Indiana University Medical Student Program for Research and Scholarship, 2022) Pamidimukkala, Ujwala; Savoy, April; Medicine, School of MedicineBackground: Elderly adults with Alzheimer’s disease-related dementia (ADRD) and type 2 diabetes tend to have difficulty in detecting hypoglycemic events. Over time, recurring hypoglycemic events increase the risk for severe consequences, such as hospitalization. Previous studies have shown continuous glucose monitoring (CGM) systems to be one of the best predictors of hypoglycemia, which can be difficult to discern normally. However, CGM systems have not been formally introduced to the ADRD population, so there is a need to understand how CGM can be incorporated into the diabetes care of elderly, cognitively impaired adults. Objective: The goal of this project is to develop a better understanding of how CGM systems can be extended to the ADRD population and what potential barriers may develop. Methods: A narrative review of how CGM systems are currently used by patients and caregivers was conducted using databases such as PubMed and Google Scholar, as well as clinical and CGM manufacturer manuals. Subsequently, a workflow extrapolated to ADRD adults was created based on these sources. Findings: A total of 118 articles, websites, and guides were obtained and evaluated. Current CGM workflows consist of 3-9 steps. A total of five potential areas for improvement have been identified. The newly constructed workflow consists of 9 steps: (1) healthcare visit, (2) CGM education, (3) CGM pick-up, (4) sensor insertion, (5) scan/calibrate, (6) evaluate data, (7) replace sensor, (8) next healthcare visit, and (9) pharmacist alterations. Conclusion: Current CGM workflows are oversimplified and do not detail processes that can be complicated for adults with diabetes and ADRD and their caregivers. However, more research still needs to be conducted to determine the severity of the identified barriers and how to overcome them. This project can inform future work on the integration of CGM into diabetes care for the ADRD population.Item Emotional distress, stress, anxiety, and the impact of the COVID-19 pandemic on early- to mid-career women in healthcare sciences research(Cambridge University Press, 2022-06-13) Bittar, Noor; Cohee, Andrea; Bhamidipalli, Surya Sruthi; Savoy, April; Ismail, Heba M.; Pediatrics, School of MedicineObjectives: The main objective of this study was to report stress and anxiety levels during the COVID-19 pandemic on early- to mid-career women researchers in healthcare sciences research and determine the associated factors. Methods: A 50-item self-administered internet questionnaire was developed using a mix of Likert-type scales and open-ended response questions. The survey was distributed June 10-August 3, 2020. Anxiety and stress as well as personal/family demands were assessed through validated measures (Patient Reported Outcomes Measurement Information System [PROMIS]-Anxiety Short Form and Perceived Stress Scale [PSS]) and open-ended responses. Results: One hundred and fifty-one early-career women in healthcare sciences research completed the survey; mean respondent age was 37.3 ± 5.2 years; and all had a college degree or higher, 50.3% holding a PhD and 35.8% MD. Race and ethnicity were reported in 128; the majority were White (74.0%). One-third (31.2%) reported being "very much" concerned about reaching their research productivity goals and 30.1% were "very much" concerned about academic promotion and tenure. Fifty percent reported a "moderate" PROMIS anxiety score and 72.1% reported a "moderate" PSS score. For the open-ended responses, 65.6% reported a worry about their professional goals because of the COVID-19 pandemic. Major concerns revolved around finances, childcare, and job security. Conclusions: Throughout the pandemic, early- and mid-career women in healthcare sciences research have reported moderate to high overall stress, anxiety, and worries. These concerns appear related to household settings, additional responsibilities, financial concerns, and reduced research productivity. Institutions and funding agencies should take these concerns into consideration and offer support.Item Electronic Co-design (ECO-design) Workshop for Increasing Clinician Participation in the Design of Health Services Interventions: Participatory Design Approach(JMIR Publications, 2022-09-22) Savoy, April; Patel, Himalaya; Shahid, Umber; Offner, Alexis D.; Singh, Hardeep; Giardina, Traber D.; Meyer, Ashley N.D.Background: Participation from clinician stakeholders can improve the design and implementation of health care interventions. Participatory design methods, especially co-design methods, comprise stakeholder-led design activities that are time-consuming. Competing work demands and increasing workloads make clinicians' commitments to typical participatory methods even harder. The COVID-19 pandemic further exacerbated barriers to clinician participation in such interventions. Objective: The aim of this study was to explore a web-based participatory design approach to conduct economical, electronic co-design (ECO-design) workshops with primary care clinicians. Methods: We adapted traditional in-person co-design workshops to web-based delivery and adapted co-design workshop series to fit within a single 1-hour session. We applied the ECO-design workshop approach to codevelop feedback interventions regarding abnormal test result follow-up in primary care. We conducted ECO-design workshops with primary care clinicians at a medical center in Southern Texas, using videoconferencing software. Each workshop focused on one of three types of feedback interventions: conversation guide, email template, and dashboard prototype. We paired electronic materials and software features to facilitate participant interactions, prototyping, and data collection. The workshop protocol included four main activities: problem identification, solution generation, prototyping, and debriefing. Two facilitators were assigned to each workshop and one researcher resolved technical problems. After the workshops, our research team met to debrief and evaluate workshops. Results: A total of 28 primary care clinicians participated in our ECO-design workshops. We completed 4 parallel workshops, each with 5-10 participants. We conducted traditional analyses and generated a clinician persona (ie, representative description) and user interface prototypes. We also formulated recommendations for future ECO-design workshop recruitment, technology, facilitation, and data collection. Overall, our adapted workshops successfully enabled primary care clinicians to participate without increasing their workload, even during a pandemic. Conclusions: ECO-design workshops are viable, economical alternatives to traditional approaches. This approach fills a need for efficient methods to involve busy clinicians in the design of health care interventions.Item Electronic Health Records’ Support for Primary Care Physicians’ Situation Awareness: A Metanarrative Review(Sage, 2023) Savoy, April; Patel, Himalaya; Murphy, Daniel R.; Meyer, Ashley N.D.; Herout, Jennifer; Singh, HardeepObjective: Situation awareness (SA) refers to people's perception and understanding of their dynamic environment. In primary care, reduced SA among physicians increases errors in clinical decision-making and, correspondingly, patients' risk of experiencing adverse outcomes. Our objective was to understand the extent to which electronic health records (EHRs) support primary care physicians (PCPs)' SA during clinical decision-making. Method: We conducted a metanarrative review of papers in selected academic databases, including CINAHL and MEDLINE. Eligible studies included original peer-reviewed research published between January 2012 and August 2020 on PCP-EHR interactions. We iteratively queried, screened, and summarized literature focused on EHRs supporting PCPs' clinical decision-making and care management for adults. Then, we mapped findings to an established SA framework to classify external factors (individual, task, and system) affecting PCPs' levels of SA (1-Perception, 2-Comprehension, and 3-Projection) and identified SA barriers. Results: From 1504 articles identified, we included and synthesized 19 studies. Study designs were largely noninterventional. Studies described EHR workflow misalignments, usability issues, and communication challenges. EHR information, including lab results and care plans, was characterized as incomplete, untimely, or irrelevant. Unmet information needs made it difficult for PCPs to obtain even basic SA, Level 1 SA. Prevalent barriers to PCPs developing SA with EHRs were errant mental models, attentional tunneling, and data overload. Conclusion: Based on our review, EHRs do not support the development of higher levels of SA among PCPs. Review findings suggest SA-oriented design processes for health information technology could improve PCPs' SA, satisfaction, and decision-making.Item Emotional distress, stress, anxiety, and the impact of the COVID-19 pandemic on early- to mid-career women in healthcare sciences research(Cambridge University Press, 2022-06-13) Bittar, Noor; Cohee, Andrea; Bhamidipalli, Surya Sruthi; Savoy, April; Ismail, Heba M.; Pediatrics, School of MedicineObjectives: The main objective of this study was to report stress and anxiety levels during the COVID-19 pandemic on early- to mid-career women researchers in healthcare sciences research and determine the associated factors. Methods: A 50-item self-administered internet questionnaire was developed using a mix of Likert-type scales and open-ended response questions. The survey was distributed June 10-August 3, 2020. Anxiety and stress as well as personal/family demands were assessed through validated measures (Patient Reported Outcomes Measurement Information System [PROMIS]-Anxiety Short Form and Perceived Stress Scale [PSS]) and open-ended responses. Results: One hundred and fifty-one early-career women in healthcare sciences research completed the survey; mean respondent age was 37.3 ± 5.2 years; and all had a college degree or higher, 50.3% holding a PhD and 35.8% MD. Race and ethnicity were reported in 128; the majority were White (74.0%). One-third (31.2%) reported being "very much" concerned about reaching their research productivity goals and 30.1% were "very much" concerned about academic promotion and tenure. Fifty percent reported a "moderate" PROMIS anxiety score and 72.1% reported a "moderate" PSS score. For the open-ended responses, 65.6% reported a worry about their professional goals because of the COVID-19 pandemic. Major concerns revolved around finances, childcare, and job security. Conclusions: Throughout the pandemic, early- and mid-career women in healthcare sciences research have reported moderate to high overall stress, anxiety, and worries. These concerns appear related to household settings, additional responsibilities, financial concerns, and reduced research productivity. Institutions and funding agencies should take these concerns into consideration and offer support.
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