The objective of this qualitative study is to better understand primary care clinician decision making for managing chronic pain. Specifically, we focus on the factors that influence changes to ...existing chronic pain management plans. Limitations in guidelines and training leave clinicians to use their own judgment and experience in managing the complexities associated with treating patients with chronic pain. This study provides insight into those judgments based on clinicians' first-person accounts. Insights gleaned from this study could inspire innovations aimed at supporting primary care clinicians (PCCs) in managing chronic pain.
We conducted 89 interviews with PCCs to obtain their first-person perspective of the factors that influenced changes in treatment plans for their patients. Interview transcripts were analyzed thematically by a multidisciplinary team of clinicians, cognitive scientists, and public health researchers.
Seven themes emerged through our analysis of factors that influenced a change in chronic pain management: 1) change in patient condition; 2) outcomes related to treatment; 3) nonadherent patient behavior; 4) insurance constraints; 5) change in guidelines, laws, or policies; 6) approaches to new patients; and 7) specialist recommendations.
Our analysis sheds light on the factors that lead PCCs to change treatment plans for patients with chronic pain. An understanding of these factors can inform the types of innovations needed to support PCCs in providing chronic pain care. We highlight key insights from our analysis and offer ideas for potential practice innovations.
Cognitive aids (CA), including emergency manuals and checklists, are tools designed to assist users in prioritizing and performing complex tasks during time sensitive, high stress situations ...(Marshall in Anesth Analgesia 117(5):1162–1171,
2013
; Marshall and Mehra in Anaesthesia 69(7):669–677,
2014
). The society for pediatric anesthesia (SPA) has developed a series of emergency checklists tailored for use by pediatric perioperative teams that cover a wide range of intraoperative critical events (Shaffner et al. in Anesth Analgesia 117(4):960–979,
2013
). In this study, we evaluated user preferences for a CA (SPA checklist) using two different presentation formats, paper and electronic, during management of simulated critical events. Anesthesia trainees managed the simulated critical events under one of three randomized conditions: (1) memory alone, (2) with a paper version of the CA, (3) with an electronic version of the CA. Following participation in the simulated critical events, participants were asked to complete a survey regarding their experience using the different versions of the CA. The percentage of favorable responses for each format of the CA was compared using a mixed effects proportional odds model. There were 143 simulated events managed by 89 anesthesia trainees. Approximately one out of three trainees (electronic 29 %, paper 30 %) assigned to use the CA chose not to use it and completed the scenario from memory alone. The survey was completed by 68 % of participants, 58 % of trainees preferred the paper version and 35 % preferred the electronic version. All survey responses that reached statistical significance favored the paper version. In this study, anesthesia trainees had a favorable opinion of the content and perceived clinical relevance of both versions of the CA. In both quantitative and qualitative analysis, the paper version of the CA was preferred over the electronic version by participants. Despite overall favorable responses to the CA, a sizeable number of participants chose not to use either version the CA during the crisis.
Major health care agencies recommend real-time ultrasound (RTUS) guidance during insertion of percutaneous central venous catheters (CVC) based on studies in which CVCs were placed by nonsurgeons. We ...conducted a meta-analysis to compare outcomes for surgeon-performed RTUS-guided CVC insertion versus traditional landmark technique.
A systematic review of the literature was performed, identifying randomized controlled trials (RCT) and prospective "safety studies" of surgeon-performed CVC insertions comparing landmark to RTUS techniques. Searches were conducted in MEDLINE, Cochrane, and Web of Science, with additional relevant articles identified through examination of the bibliographies and citations of the included studies. Two independent reviewers selected relevant studies that matched inclusion criteria, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A meta-analysis was conducted using random effects models to compare success and complication rates.
Three RCTs were identified totaling 456 patients. The RTUS guidance was associated with better first attempt success (odds ratio OR, 4.7; 95% confidence interval CI, 1.5-14.7, p = 0.008) and overall success (OR 6.5, 95% CI: 2.7-15.7, p < 0.0001). However, there were no differences in overall complication (OR 1.9 (95% CI, 0.8-4.4, p = 0.14)) or arterial puncture (OR 2.0 (95% CI, 0.7-5.6, p = 0.18) rates between the two methods.
Despite many studies involving nonsurgeons, there are only three RCTs comparing RTUS versus landmark technique for surgeon-performed CVC placement. The RTUS guidance is associated with better success than landmark technique, but no difference in complication rates. No study evaluated how RTUS was implemented. Larger studies examining RTUS use during surgeon-performed CVC placements are needed.
Systematic review and meta-analysis, level III.
Explicit guidelines are needed to develop safe and effective patient portals. This paper proposes general principles, policies, and procedures for patient portal functionality based on ...MyHealthAtVanderbilt (MHAV), a robust portal for Vanderbilt University Medical Center. We describe policies and procedures designed to govern popular portal functions, address common user concerns, and support adoption. We present the results of our approach as overall and function-specific usage data. Five years after implementation, MHAV has over 129,800 users; 45% have used bi-directional messaging; 52% have viewed test results and 45% have viewed other medical record data; 30% have accessed health education materials; 39% have scheduled appointments; and 29% have managed a medical bill. Our policies and procedures have supported widespread adoption and use of MHAV. We believe other healthcare organizations could employ our general guidelines and lessons learned to facilitate portal implementation and usage.
Cognitive task analysis (CTA) methods are traditionally used to conduct small-sample, in-depth studies. In this case study, CTA methods were adapted for a large multi-site study in which 102 ...anesthesiologists worked through four different high-fidelity simulated high-consequence incidents. Cognitive interviews were used to elicit decision processes following each simulated incident. In this paper, we highlight three practical challenges that arose: (1) standardizing the interview techniques for use across a large, distributed team of diverse backgrounds; (2) developing effective training; and (3) developing a strategy to analyze the resulting large amount of qualitative data. We reflect on how we addressed these challenges by increasing standardization, developing focused training, overcoming social norms that hindered interview effectiveness, and conducting a staged analysis. We share findings from a preliminary analysis that provides early validation of the strategy employed. Analysis of a subset of 64 interview transcripts using a decompositional analysis approach suggests that interviewers successfully elicited descriptions of decision processes that varied due to the different challenges presented by the four simulated incidents. A holistic analysis of the same 64 transcripts revealed individual differences in how anesthesiologists interpreted and managed the same case.
Burn Intensive Care Unit (BICU) work is necessarily complex and depends on clinician actions, resources, and variable patient responses to interventions. Clinicians use large volumes of data that are ...condensed in time, but separated across resources, to care for patients. Correctly designed health information technology (IT) systems may help clinicians to treat these patients more efficiently, accurately, and reliably. We report on a 3-year project to design and develop an ecologically valid IT system for use in a military BICU.
We use a mixed methods Cognitive Systems Engineering approach for research and development. Observations, interviews, artifact analysis, survey, and thematic analysis methods were used to reveal underlying factors that mold the work environment and affect clinician decisions that may affect patient outcomes. Participatory design and prototyping methods have been used to develop solutions.
We developed 39 requirements for the IT system and used them to create three use cases to help developers better understand how the system might support clinician work to develop interface prototypes. We also incorporated data mining functions that offer the potential to aid clinicians by recognizing patterns recognition of clinically significant events, such as incipient sepsis. The gaps between information sources and accurate, reliable, and efficient clinical decision that we have identified will enable us to create scenarios to evaluate prototype systems with BICU clinicians, to develop increasingly improved designs, and to measure outcomes.
The link from data to analyses, requirements, prototypes, and their evaluation ensures that the solution will reflect and support work in the BICU as it actually occurs, improving staff efficiency and patient care quality.
Abstract only Awareness in the realm of patient safety and quality improvement has become increasingly important in healthcare. Understanding the factors that influence these tenets can help improve ...the overall care for patients and potentially improve patient outcomes. One tool to assist in identifying those factors is the study of non-routine events (NREs). A non-routine event is defined as any event that deviates from optimal or expected care for a specific patient in a specific clinical situation. The goals of this study are to ascertain what aspects of their clinical encounters do patients and families view as “non-routine” and reflective of lower care safety or quality, delineate factors that influence the reporting of NREs and affect the nature of the reported NREs, and determine whether NREs obtained from patients/families significantly add to evidence about clinical system failure modes beyond that obtained from clinicians caring for the same patients. We concurrently captured and compared NRE’s reported by patients/families and their clinicians in patients having a cardiac catheterization. To date, the use of NREs to advance the quality of healthcare has primarily been identified in the surgical literature, making this project unique in regards to the use of NREs in the catheterization lab. At defined times in each care episode, trained researchers used a structured survey to identify and elucidate NREs from the patient, family members, and care providers. After we obtained informed consent, we obtained participant and system factors including individual (age, education, literacy, health status, satisfaction), contextual (self-reported stress, frustration, and performance level), and system (staffing and unit workload) factors. NREs will be characterized by incidence, source, type, and severity by two independent raters. Qualitative and multivariate statistical analyses will be performed. Of the 130 cases studied, we collected 189 patient reported NREs and 107 clinician-reported NRE’s. Ninety cases (69%) contained patient reported NREs while sixty cases (46%) contained clinician reported NREs, and forty-five (35%) cases contained both clinician and patient reported NREs. This site had 129 total patients and 130 total cases (one patient was interviewed on two separate encounters). Given ongoing data analysis, only preliminary findings can be concluded at this time: 1) patient and family members reported a substantial number of NREs with many related to the patients’ health, 2) virtually none of the patient reported NREs were reported or known by clinicians yet a substantial number were deemed relevant by patients to the quality and safety of their care, and 3) the reported NREs provided useful information about care delivery systems and how to address their shortcomings. Further studies are needed to elucidate the effect of studying patient NREs on outcomes such as morbidity and mortality.
Effective decision-making in crisis events is challenging due to time pressure, uncertainty, and dynamic decisional environments. We conducted a systematic literature review in PubMed and PsycINFO, ...identifying 32 empiric research papers that examine how trained professionals make naturalistic decisions under pressure. We used structured qualitative analysis methods to extract key themes. The studies explored different aspects of decision-making across multiple domains. The majority (19) focused on healthcare; military, fire and rescue, oil installation, and aviation domains were also represented. We found appreciable variability in research focus, methodology, and decision-making descriptions. We identified five main themes: (1) decision-making strategy, (2) time pressure, (3) stress, (4) uncertainty, and (5) errors. Recognition-primed decision-making (RPD) strategies were reported in all studies that analyzed this aspect. Analytical strategies were also prominent, appearing more frequently in contexts with less time pressure and explicit training to generate multiple explanations. Practitioner experience, time pressure, stress, and uncertainty were major influencing factors. Professionals must adapt to the time available, types of uncertainty, and individual skills when making decisions in high-risk situations. Improved understanding of these decisional factors can inform evidence-based enhancements to training, technology, and process design.
Abstract
Health information technology has contributed to improvements in quality and safety in clinical settings. However, the implementation of new technologies in health care has also been ...associated with the introduction of new sociotechnical hazards, produced through a range of complex interactions that vary with social, physical, temporal, and technological context. Other industries have been confronted with this problem and have developed advanced analytics to examine context-specific activities of workers and related outcomes. The skills and data exist in health care to develop similar insights through situational analytics, defined as the application of analytic methods to characterize human activity in situations and identify patterns in activity and outcomes that are influenced by contextual factors. This article describes the approach of situational analytics and potentially useful data sources, including trace data from electronic health record activity, reports from users, qualitative field data, and locational data. Key implementation requirements are discussed, including the need for collaboration among qualitative researchers and data scientists, organizational and federal level infrastructure requirements, and the need to implement a parallel research program in ethics to understand how the data are being used by organizations and policy makers.
Pregnancy produces important health-related needs, and expectant families have turned to technologies to meet them. The ability to predict needs and technology preferences might aid in connecting ...families with resources. This study examined the relationships among Multidimensional Health Locus of Control (MHLC) scores, information-seeking behaviors, and health-related needs in 71 pregnant women and 29 caregivers. Internal MHLC scores were positively correlated with information-seeking behaviors, including website and patient portal use. Higher Chance scores were associated with decreased portal or pregnancy website use (p=0.002), with the exception of FitPregnancy.com (p=0.02). MHLC scores were not significantly correlated with number of health-related needs or whether needs were met. Individuals with needs about disease management had higher Powerful Others scores (p=0.01); those with questions about tests had lower Powerful Others scores (p=0.008). MHLC scores might be used to identify individuals less likely to seek information and to predict need types.
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