Objective
To integrate and synthesize insights from recent studies of workarounds to the intended use of health information technology (HIT) by health care professionals.
Background
Systems are ...safest when the documentation of how work is done in policies and procedures closely matches what people actually do when they are working. Proactively identifying and managing workarounds to the intended use of technology, including deviations from expected workflows, can improve system safety.
Method
A narrative review of studies of workarounds with HIT was conducted to identify themes in the literature.
Results
Three themes were identified: (1) Users circumvented new additional steps in the workflow when using HIT, (2) interdisciplinary team members communicated via HIT in text fields that were intended for other purposes, and (3) locally developed paper-based and manual whiteboard systems were used instead of HIT to support situation awareness of individuals and groups; an example of a locally developed system was handwritten notes about a patient on a piece of paper folded up and carried in a nurse’s pocket.
Conclusion
Workarounds were employed to avoid changes to workflow, enable interdisciplinary communication, coordinate activities, and have real-time portable access to summarized and synthesized information.
Application
Implications for practice include providing summary overview displays, explicitly supporting role-based communication and coordination through HIT, and reducing the risk to reputation due to electronic monitoring of individual performance.
Macrocognition Metrics and Scenarios: Design and Evaluation for Real-World Teams translates advances in macrocognition into a format that will support immediate use by the software testing and ...evaluation community for large-scale systems, as well as real-world team trainers. It provides an overview of the theoretical foundations of macrocognition, describes new macrocognitive metrics, and provides guidance on using the metrics in the context of different approaches to evaluation and measurement of real-world teams.
Objective To determine if follicular free fatty acid (FFA) levels are associated with cumulus oocyte complex (COC) morphology. Design Prospective cohort study. Setting University in vitro ...fertilization (IVF) practice. Patient(s) A total of 102 women undergoing IVF. Intervention(s) Measurement of FFAs in serum and ovarian follicular fluid. Main Outcome Measure(s) Total and specific follicular and serum FFA levels, correlations between follicular and serum FFAs, and associations between follicular FFA levels and markers of oocyte quality, including COC morphology. Result(s) Predominant follicular fluid and serum FFAs were oleic, palmitic, linoleic, and stearic acids. Correlations between follicular and serum FFA concentrations were weak ( r = 0.252, 0.288, 0.236, 0.309, respectively for specific FFAs; r = 0.212 for total FFAs). A receiver operating characteristic curve determined total follicular FFAs ≥0.232 μmol/mL distinguished women with a lower versus higher percentage of COCs with favorable morphology. Women with elevated follicular FFAs (n = 31) were more likely to have COCs with poor morphology than others (n = 71; OR 3.3, 95% CI1.2–9.2). This relationship held after adjusting for potential confounders, including age, body mass index, endometriosis, and amount of gonadotropin administered (β = 1.2; OR 3.4, 95% CI 1.1–10.4). Conclusion(s) Elevated follicular FFA levels are associated with poor COC morphology. Further work is needed to determine what factors influence follicular FFA levels and if these factors impact fertility.
We aim to use a macrocognition theoretical perspective to characterize contributors to diagnostic delays by physicians that can be mitigated by work system redesign. As experienced with other ...complex, sociotechnical domains, system redesign is anticipated to be more effective at improving safety than training-based solutions. In the outpatient care setting, complex tasks, conducted by a primary care provider, are provided for five macrocognition functions: sensemaking, re-planning, detecting problems, deciding, and coordinating. Redesigning systems could reduce delays to diagnosis by helping users to avoid missed symptoms, forgotten follow-up activities, and delayed actions. Health information technology could support resilience strategies by offloading documentation burdens, recording working diagnoses, displaying planned follow-up activities at the correct time interval, and supporting recognition of patterns in patient care. These insights suggest a path forward for future research on system design innovations to reduce diagnostic delays, and ultimately, reduce patient harm.
•Delays to diagnosis harm patients in ambulatory care settings.•Delays to diagnosis increase with missed symptoms and follow-up activities.•Redesigning systems is more effective at reducing patient harm than training.•Five macrocognition functions provide insight for how to redesign systems.•System design innovations could better support resilience strategies.
Numerous quality improvement projects on patient handoffs have been conducted, yet standardized, reliable measurement tools remain elusive.
The literature review, which yielded approximately 400 ...relevant articles, led to the identification of seven primary functions for patient handoffs, each of which implies different interventions to improve them: (1) Framing 1, information processing is the most prevalent in the patient handoff literature; (2) Framing 2, stereotypical narratives, emphasizes highlighting deviations from typical narratives, such as a patient who is allergic to the preferred antibiotic for treating his or her diagnosed condition; (3) Framing 3, resilience, takes advantage of the transparency of the thought processes revealed through the conversation to identify erroneous assumptions and actions; (4) Framing 4, accountability, emphasizes the transfer of responsibility and authority; (5) Framing 5, social interaction, considers the perspective of the participants in the exchange; (6) Framing 6, distributed cognition, addresses how a transfer to a new care provider affects a network of specialized practitioners performing dedicated roles who may or may not be transitioning at the same time; (7) Framing 7, cultural norms, relates to how group values (instantiated as social norms for acceptable behavior) in an organization or suborganization are negotiated and maintained over time.
The diversity of handoff measurement approaches suggests a lack of consensus about the primary purpose of a handoff, as well as about what interventions are most promising for improving handoff processes. Recognizing that there are simultaneously multiple purposes for handoffs is a critical precursor to quality improvement.
Abstract
Background
Limited research exists on patient knowledge/cognition or “getting inside patients' heads.” Because patients possess unique and privileged knowledge, clinicians need this ...information to make patient-centered and coordinated treatment planning decisions. To achieve patient-centered care, we characterize patient knowledge and contributions to the clinical information space.
Methods and Objectives
In a theoretical overview, we explore the relevance of patient knowledge to care provision, apply historical perspectives of knowledge acquisition to patient knowledge, propose a representation of patient knowledge types across the continuum of care, and include illustrative vignettes about Mr. Jones. We highlight how the field of human factors (a core competency of health informatics) provides a perspective and methods for eliciting and characterizing patient knowledge.
Conclusion
Patients play a vital role in the clinical information space by possessing and sharing unique knowledge relevant to the clinical picture. Without a patient's contributions, the clinical picture of the patient is incomplete. A human factors perspective informs patient-centered care and health information technology solutions to support clinical information sharing.
Pathology Image Informatics Platform (PIIP) is an NCI/NIH sponsored project intended for managing, annotating, sharing, and quantitatively analyzing digital pathology imaging data. It expands on an ...existing, freely available pathology image viewer, Sedeen. The goal of this project is to develop and embed some commonly used image analysis applications into the Sedeen viewer to create a freely available resource for the digital pathology and cancer research communities. Thus far, new plugins have been developed and incorporated into the platform for out of focus detection, region of interest transformation, and IHC slide analysis. Our biomarker quantification and nuclear segmentation algorithms, written in MATLAB, have also been integrated into the viewer. This article describes the viewing software and the mechanism to extend functionality by plugins, brief descriptions of which are provided as examples, to guide users who want to use this platform. PIIP project materials, including a video describing its usage and applications, and links for the Sedeen Viewer, plug-ins, and user manuals are freely available through the project web page: http://pathiip.org
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Resilient system performance in high-stakes settings, which includes the ability to monitor, respond, anticipate, and learn, can be enhanced for trainees through simulation of realistic scenarios ...enhanced by augmented reality. Active learning strategies can enhance simulation-based training, particularly the mental model articulation principle where students are prompted to anticipate what will happen next and the reflection principle where students self-assess their performance compared to a gold standard expert model. In this paper, we compared simulation-based training for trauma care with and without active learning strategies during pauses in the simulated action for progressively deteriorating patients. The training was conducted online and real-time without a facilitator, with 42 medical students viewing training materials and then immediately taking an online quiz for three types of trauma cases: hemorrhage, airway obstruction, and tension pneumothorax. Participants were randomly assigned to either the experimental or control condition in a between-subjects design. We compared performance in the control and experimental conditions based on: A) the proportion of cues correctly recognized, B) the proportion of accurate diagnoses, C) the proportion of appropriate treatment interventions, and D) verbal briefing quality on a 1–5 scale. We found that the training intervention increased recognition of subtle cues critical for accurate diagnosis and appropriate treatment interventions; the training did not improve the accuracy of diagnoses or the quality of the verbal briefing. We conclude that incorporating active learning strategies in simulation-based training improved foundational capabilities in detecting subtle cues and intervening to rescue deteriorating patients that can increase the readiness for trainees to contribute to resilient system performance in the high-stakes setting of emergency care in hospitals.
We report human serum levels of selected persistent organic pollutants (POPs) categorized by age, sex, and race/ethnicity from a statistically representative sampling of the U.S. population during ...2003 and 2004. The serum levels are for several chemicals listed in the Stockholm Convention on Persistent Organic Pollutants, in the Geneva Convention on Long-Range Transboundary Air Pollution, or in both. Population data for each chemical are described by geometric means and percentiles and are categorized by age, sex, and race/ethnicity. At the 90th and 95th percentile, the dioxin total toxic equivalency (TEQ), using the 2005 toxic equivalency factors (TEFs) for all persons 12 years of age and older was 30.9 pg/g lipid (95% confidence interval (CI): 28.2−33.9 pg/g lipid) and 37.8 pg/g lipid (95% CI: 35.3−43.4 pg/g lipid), respectively. At both the 90th and 95th percentiles total TEQ increased significantly with increasing age. The population geometric mean (GM) for the total PCB concentration (sum of 35 congeners) for all persons 12 years of age and older was 0.820 ng/g whole-weight (95% CI: 0.782−0.863 ng/g whole-weight) and 134.4 ng/g lipid (95% CI: 128.9−140.0 ng/g lipid). The population 95th percentile for the total PCB concentration for all persons 12 years of age and older was 3.53 ng/g whole-weight (95% CI: 3.23−3.92 ng/g whole-weight) and 531 ng/g lipid (95% CI: 498−570 ng/g lipid). The concentrations of aldrin, endrin, γ-HCH, and o,p′-DDT were <limit of detection for all strata in the U.S. population. Hexachlorobenzene was detected in 99.9% of the persons aged 12 years and older (GM: 15.2 ng/g lipid, 95% CI: 14.5−15.9 ng/g lipid). β-HCH was detected in 69.5% of the persons aged 12 years and older (75th percentile: 14.0 ng/g lipid, 95% CI: 12.1−16.5 ng/g lipid). p,p′-DDT was detected in 73.8% of the persons aged 12 years and older (90th percentile: 11.9 ng/g lipid. 95% CI: 9.9−14.9 ng/g lipid). The DDT metabolite p,p′-DDE was detected in 99.7% of persons aged 12 years and older (GM: 238.4 ng/g lipid, 95% CI: 194.6−292.2 ng/g lipid). Oxychlordane (GM: 9.4 ng/g lipid, 95% CI: 8.7−10.1 ng/g lipid); trans-nonachlor (GM: 14.6 ng/g lipid, 95% CI: 13.1−16.5 ng/g lipid); and heptachlor epoxide (90th percentile: 13.4 ng/g lipid, 95% CI: 11.1−15.9 ng/g lipid) were detected in 82.9, 92.6, and 60% of persons aged 12 years and older, respectively. Mirex was detected in 40.7% of persons aged 12 years and older (90th percentile: 8.3 ng/g lipid, 95% CI: <LOD-13.0 ng/g lipid). Dieldrin was detected in 87.2% of persons aged 12 years and older (95th percentile: 18.9 ng/g lipid, 95% CI: 15.8−24.5 ng/g lipid).
Arctic marine ecosystems are experiencing rapid change, such as ocean warming and enhanced pollutants. Perfluoroalkyl acids (PFAAs) arriving via long-range transport have been detected in Arctic ...wildlife, including seabirds which are considered sentinels of marine ecosystem health. There is evidence that PFAA exposure leads to the disruption of thyroid hormones (THs), such as thyroxine (T4) and triiodothyronine (T3), which play important roles in metabolism, incubation, and thermoregulation in seabirds. Here, we investigated relationships between PFAAs and THs total T4 (TT4), free T4 (FT4), total T3 (TT3) and free T3 (FT3) in blood plasma collected from 63 thick-billed murres (Uria lomvia) at a colony located in northern Hudson Bay (2016–2018). We then tested if PFAAs and TH levels were related to fitness-associated reproductive traits, such as body mass and hatch dates. PFUdA, PFOS, and PFTrDA were the dominant PFAAs in murre blood, accounting for approximately 77% of ∑PFAA. Females had higher PFAAs than males, possibly due to higher trophic feeding. While FT3 increased with PFOS, PFNA, PFDA, PFDoA, PFTeDA, ∑PFCA7, and ∑PFAA in murres, TT3 decreased with PFOS, PFDoA, and PFTeDA in males, but not females, suggesting thyroid disruption. TT3 increased with body mass, whereas several long-chain PFAAs were negatively correlated with body mass. Negative relationships between PFNA, PFDoA, PFTrDA, PFTeDA, and ∑PFAA with hatch dates may be the result of a disruption in incubation behaviour, resulting in earlier hatch dates. Consequently, TT3 concentrations were highest in males and females in 2018, a year in which PFAAs were lowest and hatch dates were delayed relative to 2017. As an Arctic seabird experiencing several indirect effects of climate change, the interaction of PFAAs on thyroid activity may cause additional stress to murres.
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•Free triiodothyronine (T3) positively associated with PFOS and long-chain PFAAs.•Total T3 decreased with PFOS and long-chain PFAAs in males, suggesting disruption.•Higher trophic feeding may explain higher long chain PFAAs in females than males.•Higher long-chain PFAAs associated with lower body mass.•PFAAs associations with earlier hatch dates may be due to disruptions in incubation.
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