Lessons from implementing a combined workflow-informatics system for diabetes management

Disentangling Population Health Management Initiatives in Diabetes Care: A Scoping Review

Introduction

Population Health Management (PHM) focusses on keeping the whole population as healthy as possible. As such, it could be a promising approach for long-term health improvement in type 2 diabetes. This scoping review aimed to examine the extent to which and how PHM is used in the care for people with type 2 diabetes.

Methods

PubMed, Web of Science, and Embase were searched between January 2000 and September 2021 for papers on self-reported PHM initiatives for type 2 diabetes. Eligible initiatives were described using the analytical framework for PHM.

Results

In total, 25 studies regarding 18 PHM initiatives for type 2 diabetes populations were included. There is considerable variation in whether and how the PHM steps are operationalized in existing PHM initiatives. Population identification, impact evaluation, and quality improvement processes were generally part of the PHM initiatives. Triple Aim assessment and risk stratification actions were scarce or explained in little detail. Moreover, cross-sector integration is key in PHM but scarce in practice.

Conclusion

Operationalization of PHM in practice is limited compared to the PHM steps described in the analytical framework. Extended risk stratification and integration efforts would contribute to whole-person care and further health improvements within the population.

Understanding Providers' Readiness and Attitudes Toward Autoantibody Screening: A Mixed-Methods Study

Screening for autoantibodies associated with type 1 diabetes can identify people most at risk for progressing to clinical type 1 diabetes and provide an opportunity for early intervention. Drawbacks and barriers to screening exist, and concerns arise, as methods for disease prevention are limited and no cure exists today. The availability of novel treatment options such as teplizumab to delay progression to clinical type 1 diabetes in high-risk individuals has led to the reassessment of screening programs. This study explored awareness, readiness, and attitudes of endocrinology providers toward type 1 diabetes autoantibody screening.

The Implementation and Acceptability of a Mobile Application for Screening for Atrial Fibrillation at Home

Introduction: Although patients are able to easily record electrocardiograms using consumer devices, these are typically not shared with their clinicians. This article discusses the development and acceptability of a mobile application (app) that integrates with the electronic health record to facilitate screening for atrial fibrillation (AF). Methods: After app development and implementation, we compared workflows with and without the mobile app. Seven older adults used it during a prospective twice-daily 2-week home-based AF screening protocol and completed an acceptability survey with Likert scale responses. Results: Compliance with the screening protocol was 82%. Acceptability and usability was favorable. Patients reported confidence in the connection between the app and their medical record. Discussion: The availability of apps to capture data and facilitate a connection with health systems is critical. The app developed is a feasible solution for older patients with AF to self-monitor and report results to their health provider.

Surgical Workflow Management Schemata for Cataract Procedures

Objective: Workflow guidance of surgical activities is a challenging task. Because of variations in patient properties and applied surgical techniques, surgical processes have a high variability. The objective of this study was the design and implementation of a surgical workflow management system (SWFMS) that can provide a robust guidance for surgical activities. We investigated how many surgical process models are needed to develop a SWFMS that can guide cataract surgeries robustly.

Methods: We used 100 cases of cataract surgeries and acquired patient-individual surgical process models (iSPMs) from them. Of these, randomized subsets iSPMs were selected as learning sets to create a generic surgical process model (gSPM). These gSPMs were mapped onto workflow nets as work-flow schemata to define the behavior of the SWFMS. Finally, 10 iSPMs from the disjoint set were simulated to validate the workflow schema for the surgical processes. The measurement was the successful guidance of an iSPM.

Results: We demonstrated that a SWFMS with a workflow schema that was generated from a subset of 10 iSPMs is sufficient to guide approximately 65% of all surgical processes in the total set, and that a subset of 50 iSPMs is sufficient to guide approx. 80% of all processes.

Conclusion: We designed a SWFMS that is able to guide surgical activities on a detailed level. The study demonstrated that the high inter-patient variability of surgical processes can be considered by our approach.

Options for Diabetes Management in Sub-Saharan Africa with an Electronic Medical Record System

Background: An increase of diabetes prevalence of up to 80% is predicted in subSaharan Africa (SSA) by 2025 exceeding the worldwide 55%. Mortality rates of diabetes and HIV/AIDS are similar. Diabetes shares several common factors with HIV/AIDS and multidrug-resistant tuberculosis (MDR-TB). The latter two health problems have been efficiently managed by an open source electronic medical record system (EMRS) in Latin America. Therefore a similar solution for diabetes in SSA could be extremely helpful.

Objectives: The aim was to design and validate a conceptual model for an EMRS to improve diabetes management in SSA making use of the HIV and TB experience.

Methods: A review of the literature addressed diabetes care and management in SSA as well as existing examples of information and communication technology (ICT) use in SSA. Based on a need assessment conducted in SSA a conceptual model based on the traditionally structured healthcare system in SSA was mapped into a three-layer structure. Application modules were derived and a demonstrator programmed based on an open source EMRS. Then the approach was validated by SSA experts.

Results: A conceptual model could be specified and validated which enhances a problem-oriented approach to diabetes management processes. The prototyp EMRS demonstrates options for a patient portal and simulation tools for education of health professional and patients in SSA.

Conclusion: It is possible to find IT solutions for diabetes care in SSA which follow the same efficiency concepts as HIV or TB modules in Latin America. The local efficiency and sustainability of the solution will, however, depend on training and changes in work behavior.

Mapping Multi-Site Clinic Workflows to Design Systems-Enabled Interventions

Objective

Variations in processes for different clinics and health systems can dramatically change the way preventive interventions are implemented. We present a method for documenting these variations using workflow diagrams and demonstrate how understanding workflow aided an electronic health record (EHR) embedded colorectal cancer screening intervention.

Materials and Methods

We mapped variation in processes for ordering and documenting fecal testing, current colonoscopy, prior colonoscopies, and pathology results. This work was part of a multi-site cluster-randomized pragmatic trial to test a mailed approach to offering fecal testing at 26 safety net clinics (in eight organizations) in Oregon and Northern California. We created clinic-specific workflow diagrams and then distilled them into consolidated diagrams that captured the variations.

Results

Clinics had varied practices for storing and using information about colorectal cancer screening. Developing workflow diagrams of key processes enabled clinics to find optimal ways to send fecal test kits to patients due for screening. The workflows informed the rollout of new EHR tools and identified best practices for data capture.

Discussion

Diagramming workflows can have great utility when implementing and refining EHR tools for clinical practice, especially when doing so across multiple clinical sites. The process of developing the workflows uncovered successful practice recommendations and revealed limitations and potential effects of a research intervention.

Conclusion

Our method of documenting clinical process variation might inform other EHR-powered, multi-site research and can improve data feedback from EHR systems to clinical caregivers.

A population management system for improving colorectal cancer screening in a primary care setting

RATIONALE

Provision of colorectal cancer (CRC) screening in primary care is suboptimal; failure to observe screening guidelines poses unnecessary risks to patients and doctors.

AIMS AND OBJECTIVES

Implement a population management system for CRC screening; evaluate impact on compliance with evidence-based guidelines.

DESIGN

A quasi-experimental, prospective quality improvement study design using pre-post-analyses with concurrent controls.

SETTING

Six suites within an academic primary care practice.

PARTICIPANTS

5320 adults eligible for CRC screening treated by 70 doctors.

INTERVENTION

In three intervention suites, doctors reviewed real-time rosters of patients due for CRC screening and chose practice delegate outreach or default reminder letter. Delegates tracked overdue patients, made outreach calls, facilitated test ordering, obtained records and documented patient deferral, exclusion or decline. In three control suites, doctors followed usual preventive care practices.

MAIN OUTCOME MEASURES

CRC screening compliance (including documented decline, deferral or exclusion) and CRC screening completion rates over 5 months.

RESULTS

At baseline, there was no significant difference in CRC screening compliance (I: 80.4% and C: 79.6%, P = 0.439) and CRC screening completion rates (I: 78.3% and C: 77.3%, P = 0.398) between intervention and control groups. Post-intervention, compliance rates (I: 88.1% and C: 80.5%, P < 0.01) and completion rates (I: 81.0% and C: 78.1%, P < 0.05) were significantly higher in the intervention group.

CONCLUSIONS

A population management system using closed-loop communication may improve CRC screening compliance and completion rates within academic primary care practices. Team-based care using well-designed IT systems can enable sharing of patient care responsibilities and improve patient outcomes.

Innovative methods for parents and clinics to create tools for kids' care (IMPACCT Kids' Care) study protocol

BACKGROUND

Despite expansions in public health insurance, many children remain uninsured or experience gaps in coverage. Community health centers (CHCs) provide primary care to many children at risk for uninsurance and are well-positioned to help families obtain and retain children's coverage. Recent advances in health information technology (HIT) capabilities provide the means to create tools that could enhance CHCs' insurance outreach efforts.

OBJECTIVE

To present the study design, baseline patient characteristics, variables, and statistical methods for the Innovative Methods for Parents And Clinics to Create Tools for Kids' Care (IMPACCT Kids' Care) study.

METHODS/DESIGN

In this mixed methods study, we will design, test and refine health insurance outreach HIT tools through a user-centered process. We will then implement the tools in four CHCs and evaluate their effectiveness and barriers and facilitators to their implementation. To measure effectiveness, we will quantitatively assess health insurance coverage continuity and utilization of healthcare services for pediatric patients in intervention CHCs compared to matched control sites using electronic health record (EHR) and Oregon Medicaid administrative data over 18months pre- and 18months post-implementation (n=34,867 children). We will also qualitatively assess the implementation process to understand how the tools fit into the clinics' workflows and the CHC staff experiences with the tools.

CONCLUSIONS

This study creates, implements, and evaluates health insurance outreach HIT tools. The use of such tools will likely improve care delivery and health outcomes, reduce healthcare disparities for vulnerable populations, and enhance overall healthcare system performance. ClinicalTrials.gov Identifier: NCT02298361.

Applying systems engineering to implement an evidence-based intervention at a community health center

Impressive results in patient care and cost reduction have increased the demand for systems-engineering methodologies in large health care systems. This Report from the Field describes the feasibility of applying systems-engineering techniques at a community health center currently lacking the dedicated expertise and resources to perform these activities.

Health care worker perspectives inform optimization of patient panel-support tools: a qualitative study

Electronic decision-support systems appear to enhance care, but improving both tools and work practices may optimize outcomes. Using qualitative methods, the authors' aim was to evaluate perspectives about using the Patient Panel-Support Tool (PST) to better understand health care workers' attitudes toward, and adoption and use of, a decision-support tool. In-depth interviews were conducted to elicit participant perspectives about the PST-an electronic tool implemented in 2006 at Kaiser Permanente Northwest. The PST identifies "care gaps" and recommendations in screening, medication use, risk-factor control, and immunizations for primary care panel patients. Primary care physician (PCP) teams were already grouped (based on performance pre- and post-PST introduction) into lower, improving, and higher percent-of-care-needs met. Participants were PCPs (n=21), medical assistants (n=11), and quality and other health care managers (n=20); total n=52. Results revealed that the most commonly cited benefit of the PST was increased in-depth knowledge of patient panels, and empowerment of staff to do quality improvement. Barriers to PST use included insufficient time, competing demands, suboptimal staffing, tool navigation, documentation, and data issues. Facilitators were strong team staff roles, leadership/training for tool implementation, and dedicated time for tool use. Higher performing PCPs and their assistants more often described a detailed team approach to using the PST. In conclusion, PCP teams and managers provided important perspectives that could help optimize use of panel-support tools to improve future outcomes. Improvements are needed in tool function and navigation; training; staff accountability and role clarification; and panel management time.

Multilevel research and the challenges of implementing genomic medicine

Advances in genomics and related fields promise a new era of personalized medicine in the cancer care continuum. Nevertheless, there are fundamental challenges in integrating genomic medicine into cancer practice. We explore how multilevel research can contribute to implementation of genomic medicine. We first review the rapidly developing scientific discoveries in this field and the paucity of current applications that are ready for implementation in clinical and public health programs. We then define a multidisciplinary translational research agenda for successful integration of genomic medicine into policy and practice and consider challenges for successful implementation. We illustrate the agenda using the example of Lynch syndrome testing in newly diagnosed cases of colorectal cancer and cascade testing in relatives. We synthesize existing information in a framework for future multilevel research for integrating genomic medicine into the cancer care continuum.

Mediation of adoption and use: a key strategy for mitigating unintended consequences of health IT implementation

OBJECTIVE

Without careful attention to the work of users, implementation of health IT can produce new risks and inefficiencies in care. This paper uses the technology use mediation framework to examine the work of a group of nurses who serve as mediators of the adoption and use of a barcode medication administration (BCMA) system in an inpatient setting.

MATERIALS AND METHODS

The study uses ethnographic methods to explore the mediators' work. Data included field notes from observations, documents, and email communications. This variety of sources enabled triangulation of findings between activities observed, discussed in meetings, and reported in emails.

RESULTS

Mediation work integrated the BCMA tool with nursing practice, anticipating and solving implementation problems. Three themes of mediation work include: resolving challenges related to coordination, integrating the physical aspects of BCMA into everyday practice, and advocacy work.

DISCUSSION

Previous work suggests the following factors impact mediation effectiveness: proximity to the context of use, understanding of users' practices and norms, credibility with users, and knowledge of the technology and users' technical abilities. We describe three additional factors observed in this case: 'influence on system developers,' 'influence on institutional authorities,' and 'understanding the network of organizational relationships that shape the users' work.'

CONCLUSION

Institutionally supported clinicians who facilitate adoption and use of health IT systems can improve the safety and effectiveness of implementation through the management of unintended consequences. Additional research on technology use mediation can advance the science of implementation by providing decision-makers with theoretically durable, empirically grounded evidence for designing implementations.

The future of health information technology in the patient-centered medical home

Most electronic health records today need further development of features that patient-centered medical homes require to improve their efficiency, quality, and safety. We propose a road map of the domains that need to be addressed to achieve these results. We believe that the development of electronic health records will be critical in seven major areas: telehealth, measurement of quality and efficiency, care transitions, personal health records, and, most important, registries, team care, and clinical decision support for chronic diseases. To encourage this development, policy makers should include medical homes in emerging electronic health record regulations. Additionally, more research is needed to learn how these records can enhance team care.

Comparison of Computer-based Clinical Decision Support Systems and Content for Diabetes Mellitus

BACKGROUND

Computer-based clinical decision support (CDS) systems have been shown to improve quality of care and workflow efficiency, and health care reform legislation relies on electronic health records and CDS systems to improve the cost and quality of health care in the United States; however, the heterogeneity of CDS content and infrastructure of CDS systems across sites is not well known.

OBJECTIVE

We aimed to determine the scope of CDS content in diabetes care at six sites, assess the capabilities of CDS in use at these sites, characterize the scope of CDS infrastructure at these sites, and determine how the sites use CDS beyond individual patient care in order to identify characteristics of CDS systems and content that have been successfully implemented in diabetes care.

METHODS

We compared CDS systems in six collaborating sites of the Clinical Decision Support Consortium. We gathered CDS content on care for patients with diabetes mellitus and surveyed institutions on characteristics of their site, the infrastructure of CDS at these sites, and the capabilities of CDS at these sites.

RESULTS

The approach to CDS and the characteristics of CDS content varied among sites. Some commonalities included providing customizability by role or user, applying sophisticated exclusion criteria, and using CDS automatically at the time of decision-making. Many messages were actionable recommendations. Most sites had monitoring rules (e.g. assessing hemoglobin A1c), but few had rules to diagnose diabetes or suggest specific treatments. All sites had numerous prevention rules including reminders for providing eye examinations, influenza vaccines, lipid screenings, nephropathy screenings, and pneumococcal vaccines.

CONCLUSION

Computer-based CDS systems vary widely across sites in content and scope, but both institution-created and purchased systems had many similar features and functionality, such as integration of alerts and reminders into the decision-making workflow of the provider and providing messages that are actionable recommendations.

Helping high-risk youth move through high-risk periods: personally controlled health records for improving social and health care transitions

BACKGROUND

New patient-centered information technologies are needed to address risks associated with health care transitions for adolescents and young adults with diabetes, including systems that support individual and structural impediments to self- and clinical-care.

METHODS

We describe the personally controlled health record (PCHR) system platform and its key structural capabilities and assess its alignment with tenets of the chronic care model (CCM) and the social-behavioral and health care ecologies within which adolescents and young adults with diabetes mature.

RESULTS

Configured as Web-based platforms, PCHRs can support a new class of patient-facing applications that serve as monitoring and support systems for adolescents navigating complex social, developmental, and health care transitions. The approach can enable supportive interventions tailored to individual patient needs to boost adherence, self-management, and monitoring.

CONCLUSIONS

The PCHR platform is a paradigm shift for the organization of health information systems and is consistent with the CCM and conceptualizations of patient- and family-centered care for diabetes. Advancing the approach augers well for improvement around health care transitions for youth and also requires that we address (i) structural barriers impacting diabetes care for maturing youth; (ii) challenges around health and technology literacy; (iii) privacy and confidentiality issues, including sharing of health information within family and institutional systems; and (iv) needs for evaluation around uptake, impacts, and outcomes.

Proclets in healthcare

Healthcare processes can be characterized as weakly-connected interacting light-weight workflows coping with different levels of granularity. Classical workflow notations fall short in supporting these kind of processes. Although these notations are able to describe the life-cycle of individual cases and allow for hierarchical decomposition, they primarily support monolithic processes. However, they are less suitable for healthcare processes. The Proclets framework is one formalism that provides a solution to this problem. Based on a large case study, describing the diagnostic process of the gynecological oncology care process at the Academic Medical Center (AMC), we identify the limitations of "monolithic workflows". Moreover, by using the same case study, we investigate whether healthcare processes can be described effectively using Proclets. In this way, we provide a comparison between the Proclet framework and existing workflow languages and identify research challenges.

CEDRIC: a computerized chronic disease management system for urban, safety net clinics

To meet the challenge of improving health care quality in urban, medically underserved areas of the US that have a predominance of chronic diseases such as diabetes, we have developed a new information system called CEDRIC for managing chronic diseases. CEDRIC was developed in collaboration with clinicians at an urban safety net clinic, using a community-participatory partnered research approach, with a view to addressing the particular needs of urban clinics with a high physician turnover and large uninsured/underinsured patient population. The pilot implementation focuses on diabetes management. In this paper, we describe the system's architecture and features.

Describing and modeling workflow and information flow in chronic disease care

OBJECTIVES

The goal of the study was to develop an in-depth understanding of work practices, workflow, and information flow in chronic disease care, to facilitate development of context-appropriate informatics tools.

DESIGN

The study was conducted over a 10-month period in three ambulatory clinics providing chronic disease care. The authors iteratively collected data using direct observation and semi-structured interviews.

MEASUREMENTS

The authors observed all aspects of care in three different chronic disease clinics for over 150 hours, including 157 patient-provider interactions. Observation focused on interactions among people, processes, and technology. Observation data were analyzed through an open coding approach. The authors then developed models of workflow and information flow using Hierarchical Task Analysis and Soft Systems Methodology. The authors also conducted nine semi-structured interviews to confirm and refine the models.

RESULTS

The study had three primary outcomes: models of workflow for each clinic, models of information flow for each clinic, and an in-depth description of work practices and the role of health information technology (HIT) in the clinics. The authors identified gaps between the existing HIT functionality and the needs of chronic disease providers.

CONCLUSIONS

In response to the analysis of workflow and information flow, the authors developed ten guidelines for design of HIT to support chronic disease care, including recommendations to pursue modular approaches to design that would support disease-specific needs. The study demonstrates the importance of evaluating workflow and information flow in HIT design and implementation.