This practice-based PhD project develops a ‘Sonic Ghosting' practice through a portfolio of compositions, installations and performances. Sonic Ghosting, as a mode of creative endeavor, offers a way ...to interrogate the relationship between space/place/memory and sound/music/noise by fracturing the soundscape of the present with the echoes, phantoms and potentialities of the soundscapes of the past/future. In one sense, it is ventriloquising the material/space/landscape that it engages with, extending it beyond the bounds of its normal sonic existence, and blurring the horizon between what is unheard/unseen but felt, and what is actually present. To achieve this, there is a creative and compositional employment of fracture, degradation and performance interruption – both temporally and spatially. Where sonic material is gleaned from on-site field recordings it is manipulated, cut-up, processed, delayed, moved in time and space. This process creates layers within the fabric of the work, between the memory of sound onsite, the recordings, their fractured remains, electronic and acoustic instrumentation, and the multiple modes of presentation and iteration: performance, installation, documentation, image, text. In some examples the resulting work is also presented in-situ alongside the soundscape of the place/space about which the work is made, or contextualised, with text/image/materials. The included portfolio contains documentation of a series of experimental works that explore a number of different creative modes, forms, and stimuli. These are: Chalk Pit, an installation and improvised performance interruption exploring the post-industrial landscape of the Sussex chalk industry; Ghosting the Periphery, a four channel presence-responsive installation exploring the gallery and peripheral spaces of the Hatton Gallery in Newcastle-upon-Tyne; Branch Lines, a composition and graphic score for Violin, Cello, Clarinet and Piano, exploring experiences of Causey Arch railway bridge in County Durham; Thrumming Halls, a movement/noise responsive installation presented binaurally, reflecting on the Barnsley National Union of Mineworkers Hall, inhabitants and spaces; Underdrift, an electroacoustic composition reflecting on the spaces around the Co-Operative Pioneer's Museum, Town Hall, and streets of Rochdale, Greater Manchester. In addition, the portfolio contains documentation of the final exhibition, Sonic Ghostings, presented at the Attenborough Centre for the Creative Arts, which incorporates the portfolio works alongside working materials, and brings the principles of a Sonic Ghosting practice to bear on the broader research project itself through a final composition: Fractures and Fragments. The accompanying commentary provides a critical and conceptual outline of a Sonic Ghosting practice, a reflective commentary on each of the portfolio works, and an overview of the experimental and creative research process undertaken over the course of the research project. It explores a range of relevant critical theory in order to consider how a Sonic Ghosting practice, and the specific portfolio works in question, interrogate the role of sound/music composition in exploring memory, space, place, ruin, landscape, hauntology and the spectral turn. It draws reference to a range of sources including key texts from sound and music studies (Salomé Voegelin, Sabine Vogel, Bennett Hogg, Anna Friz, Curtis Roads), cultural studies (Jacques Derrida, Fredrik Jameson, Michel de Certeau, Rebecca Solnit), and human geography (Tim Edensor, Nigel Thrift). The commentary also considers the artistic contexts of Sonic Ghosting, with a review of work by Jimi Hendrix, Robert van Heumen, and Chris Watson, as well as influences on specific works such as Kurt Schwitters, William Burroughs, Hildegard Westercamp, and John Cage.
Introduction:
Adoption of a new Electronic Health Record (EHR) can introduce radical changes in task allocation, work processes, and efficiency for providers. In June 2019, The Ottawa Hospital ...transitioned from a primarily paper based EHR to a comprehensive EHR (Epic) using a “big bang” approach. The objective of this study was to assess the impact of the transition to Epic on Emergency Physician (EP) work activities in a tertiary care academic Emergency Department (ED).
Methods:
We conducted a time motion study of EPs on shift in low acuity areas of our ED (CTAS 3-5). Fifteen EPs representing a spectrum of pre-Epic baseline workflow efficiencies were directly observed in real-time during two 4-hour sessions prior to EHR implementation (May 2019) and again in go live (August 2019). Trained observers performed continuous observation and measured times for the following EP tasks: chart review, direct patient care, documentation, physical movement, communication, teaching, handover, and other (including breaks). We compared time spent on tasks pre Epic and during go live and report mean times for the EP tasks per patient and per shift using two tailed t-test for comparison.
Results:
All physicians had a 17% decrease in patients seen after Epic implementation (2.72/hr vs 2.24/hr, p < 0.01). EPs spent the same amount of time per patient on direct patient care and chart review (direct patient care: 9min06sec/pt pre vs 8min56sec/pt go live, p = 0.77; chart review: 2min47sec/pt pre vs 2min50sec/pt go live, p = 0.88), however, documentation time increased (5min28sec/pt pre vs 7min12sec/pt go live, p < 0.01). Time spent on shift teaching learners increased but did not reach statistical significance (31min26sec/shift pre vs 36min21sec/shift go live, p = 0.39), and time spent on non-patient-specific activities – physical movement, handover, team communication, and other – did not change (50min49sec/shift pre vs 50min53sec/shift go live, p = 0.99).
Conclusion:
Implementation of Epic did not affect EP time with individual patients - there was no change in direct patient care or chart review. Documentation time increased and EP efficiency (patients seen per hr on shift) decreased after go live. Patient volumes cannot be adjusted in the ED therefore anticipating the EHR impact on EP workflow is critical for successful implementation. EDs may consider up staffing 20% during go live. Findings from this study can inform how to best support EDs nationally through transition to EHR.
More Time for Doctoring Hunt, Rachel J; Fletcher, Shelley; Rock, Jack P ...
Neurosurgery,
12/2020, Letnik:
67, Številka:
Supplement_1
Journal Article
Recenzirano
INTRODUCTION The introduction of the electronic medical record (EMR) has significantly changed physician workflow. Staying late to finish notes is the norm, and the documentation burden imposed by ...EMR has been cited as a significant factor in physician burnout. Junior surgical residents in some institutions have been reported to spend as much as 30% of their time on chart review and documentation. METHODS The neurosurgery written handoff, previously designed by the Henry Ford neurosurgery residents to improve communication during patient handoff, was reviewed with medical coders. With minor alterations to the template, the information contained in the written handoff was determined to be sufficient for billing requirements. The written handoff was then filed as the daily physician progress note in lieu of the traditional SOAP note. After one year, the incidence of coding queries and missed billing opportunities were audited to ensure that billing was not negatively impacted. RESULTS The integrated progress note/handoff format was implemented in February of 2019. Because maintaining a written handoff was already vital to team workflow, the integrated note/handoff format essentially removed the busywork of writing daily progress notes. Residents unanimously reported a decrease in time spent on documentation. Progress note-related coding queries decreased by 44%. Missed billing opportunities due to insufficient documentation decreased by 67%. There was no change in the incidence of coding queries related to other forms of documentation. CONCLUSION Integration of a written handoff with physician daily progress note decreased physician documentation burden while simultaneously improving note usability for billing. Prior studies have shown that the use of standardized written handoff significantly reduces medical errors. Combining the concept of the physician progress note with a written handoff has the potential to improve patient care while simulataneously providing junior neurosurgery residents with more time to spend honing their operative skills.
In early 2018, the Centers for Medicare & Medicaid Services released the Medical Review of Evaluation and Management (E/M) Documentation, which allows supervising teaching physicians to rely on a ...medical student’s documentation to support billing for E/M services. This change has potential to enhance education, clinical documentation quality, and the satisfaction of students, postgraduate trainees, and teaching physicians. However, its practical adoption presents many challenges that must be navigated successfully to realize these important goals in compliance with federal and local requirements, while avoiding unintended downstream problems. Implementation requires careful planning, policy creation, education, and monitoring, all with collaboration between institutional leaders, compliance and information technology professionals, educators, and learners. In this paper, we review the 2018 Centers for Medicare & Medicaid Services rule change, address common questions and potential impacts, outline practical workflows to meet the supervision requirement, and discuss steps for successful implementation.
There was a statistically significant increase in the rate of documentation of the following: whether the child was previously registered on the CPR, whether the event was witnessed, specific time of ...the injury, where the injury occurred, administration of first aid, presence of other injuries, total body surface area affected, a pictorial representation of the injury, developmental level of the child and compatibility of history with this.
ObjectiveTo minimise the rates of avoidable error in the collection, processing and documentation of cerebrospinal fluid (CSF) samples acquired to investigate neurological emergencies.MethodsTo ...identify common and avoidable sources of error, CSF samples sent for suspected subarachnoid haemorrhage or bacterial meningitis were considered retrospectively. A total of 30 CSF samples were sent between May and September 2018 from the Whipps Cross University Hospital Acute Admissions Unit. Based upon the sources of error identified, a series of interventions were devised to minimise future error. Error rates were reassessed between December 2018 and May 2019 after implementation of each intervention, over 2 ‘PDSA’ cycles.ResultsAvoidable sample processing errors (e.g. under-filled bottles, inadequate requests) were reduced by a simple information sheet introduced to lumbar puncture (LP) packs. Deficiencies in documentation of LP procedures were overcome with the introduction of a structured computer template to be filled out after each procedure. Length of admission reduced from an average of 79 hours (pre-implementation) to 43 hours (after cycle 2).ConclusionsThree straightforward, ‘one-off’ and easily reproducible interventions led to considerably reduced rates of error in the processing and documentation of CSF samples for acute neurological emergencies.
Medical scribes have been utilized to reduce electronic health record (EHR) associated documentation burden. Although evidence suggests benefits to scribes, no large-scale studies have quantitatively ...evaluated scribe impact on physician documentation across clinical settings. This study aimed to evaluate the effect of scribes on physician EHR documentation behaviors and performance.
This retrospective cohort study used EHR audit log data from a large academic health system to evaluate clinical documentation for all ambulatory encounters between January 2014 and December 2019 to evaluate the effect of scribes on physician documentation behaviors. Scribe services were provided on a first-come, first-served basis on physician request. Based on a physician's scribe use, encounters were grouped into 3 categories: never using a scribe, prescribe (before scribe use), or using a scribe. Outcomes included chart closure time, the proportion of delinquent charts, and charts closed after-hours.
Three hundred ninety-five physicians (23% scribe users) across 29 medical subspecialties, encompassing 1,132,487 encounters, were included in the analysis. At baseline, scribe users had higher chart closure time, delinquent charts, and after-hours documentation than physicians who never used scribes. Among scribe users, the difference in outcome measures postscribe compared with baseline varied, and using a scribe rarely resulted in outcome measures approaching a range similar to the performance levels of nonusing physicians. In addition, there was variability in outcome measures across medical specialties and within similar subspecialties.
Although scribes may improve documentation efficiency among some physicians, not all will improve EHR-related documentation practices. Different strategies may help to optimize documentation behaviors of physician-scribe dyads and maximize outcomes of scribe implementation.
Software developers need access to different kinds of information which is often dispersed among different documentation sources, such as API documentation or Stack Overflow. We present an approach ...to automatically augment API documentation with "insight sentences" from Stack Overflow -- sentences that are related to a particular API type and that provide insight not contained in the API documentation of that type. Based on a development set of 1,574 sentences, we compare the performance of two state-of-the-art summarization techniques as well as a pattern-based approach for insight sentence extraction. We then present SISE, a novel machine learning based approach that uses as features the sentences themselves, their formatting, their question, their answer, and their authors as well as part-of-speech tags and the similarity of a sentence to the corresponding API documentation. With SISE, we were able to achieve a precision of 0.64 and a coverage of 0.7 on the development set. In a comparative study with eight software developers, we found that SISE resulted in the highest number of sentences that were considered to add useful information not found in the API documentation. These results indicate that taking into account the meta data available on Stack Overflow as well as part-of-speech tags can significantly improve unsupervised extraction approaches when applied to Stack Overflow data.
PDF
