OBJECTIVE:Emergency services utilization is increasing in older adult populations. Many such encounters may be preventable with better access to acute care in the community. Mobile integrated health (MIH) programs leverage mobile resources to deliver care and services to patients in the out-of-hospital environment and have the potential to improve clinical outcomes and decrease health care costs; however, they have not been widely implemented. We assessed barriers, potential facilitators, and other factors critical to the implementation of MIH programs with key vested partners. METHODS:Professional and community-member partners were purposefully recruited to participate in recorded structured interviews. The study team used the Practical Robust Implementation and Sustainability Model (PRISM) framework to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes across partner groups. RESULTS:The study team interviewed 22 participants (mean age 56, 68% female). A cohort of professional subject matter experts included physicians, paramedics, public health personnel, and hospital administrators. A cohort of lay community partners included patients and caregivers. Coders identified three prominent themes that impact MIH implementation. First, MIH is disruptive to existing clinical workflows. Second, using MIH to improve patients' experience during acute care encounters is key to intervention adoption. Finally, legislative action is needed to augment central financial and regulatory policies to ensure the adoption of MIH programs. CONCLUSIONS:Common themes impacting the implementation of MIH programs were identified across vested partner groups. Multilevel strategies are needed to address patient adoption, clinical partners' workflow, and legislative policies to ensure the success of MIH programs.

Healthcare delivery in the United States has been characterized as overly reactive and dependent on emergency department care for safety net coverage, with opportunity for improvement around discharge planning and high readmissions and emergency department bounce-back rates. Community paramedicine is a recent healthcare innovation that enables proactive visitation of patients at home, often shortly after emergency department and hospital discharge. We establish the first optimization-based framework to study efficiencies in the management and operation of a community paramedicine program. The collective innovations of our modeling include i) a novel hierarchical objective function with the goals of fairly increasing patient welfare, lowering hospital costs, and reducing readmissions and emergency department visits, ii) a new constraint set that ensures priority same-day visits for emergent patients, and iii) a further extension of our model to determine the minimum supplemental resources necessary to ensure feasibility in a single optimization formulation. Our medical-need based objective function prioritizes patients based on their clinical features and seeks to select and schedule patient visits and route healthcare providers to maximize overall patient welfare while favoring shorter tours. We use our methods to develop managerial insights via computational experiments on a variety of test instances based on real data from a hospital system in Upstate New York. We are able to identify optimal and nearly optimal tours that efficiently select, route, and schedule patients in reasonable timeframes. Our results lead to insights that can support managerial decisions about establishing (and improving existing) community paramedicine programs.

BACKGROUND:Emergency departments (EDs) are important for preventing suicide. Historically, many patients with suicide risk are not detected during routine clinical care, and those who are often do not receive suicide-specific intervention. The original Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE 1) study examined the implementation of universal suicide risk screening and a multi-component ED-initiated suicide prevention intervention.PURPOSE:The ED-SAFE 2 aims to study the impact of using a continuous quality improvement approach (CQI) to improve suicide related care, with a focus on improving universal suicide risk screening in adult ED patients and evaluating implementation of a new brief intervention called the Safety Planning Intervention (SPI) into routine clinical practice. CQI is a quality management process that uses data and collaboration to drive incremental, iterative improvements. The SPI is a personalized approach that focuses on early identification of warning signs and execution of systematic steps to manage suicidal thoughts. ED-SAFE 2 will provide data on the effectiveness of CQI procedures in improving suicide-related care processes, as well as the impact of these improvements on reducing suicide-related outcomes.METHODS:Using a stepped wedge design, eight EDs collected data cross three study phases: Baseline (retrospective), Implementation (12 months), and Maintenance (12 months). Lean methods, a specific approach to pursuing CQI which focuses on increasing value and eliminating waste, were used to evaluate and improve suicide-related care.CONCLUSIONS:The results will build upon the success of the ED-SAFE 1 and will have a broad public health impact through promoting better suicide-related care processes and improved suicide prevention.

Lean principles provide systematic guidelines for designing effective processes, focusing on eliminating waste by specifying value, simplifying flow, and pulling from customer demand.Lean ideas have transformed process design and significantly improved lead times, quality and cost for many manufacturing companies.While lean principles are simply stated, the design process is complicated because every process has unique constraints and competitive drivers.In this paper, we examine the issue of how to use hands-on materials to teach lean design, and in particular, the value of inquiry and the use of multiple methods within the same course.We examine these issues in the context a physical process simulation, and discuss the use of case studies and a short game about variability to explore how different approaches to teaching lean topics build depth of understanding.We present preliminary results of the effects on student learning across implementations at five universities.

Organizations have demonstrated increasing interest in both leaning and greening activities. Lean manufacturing practices, with an emphasis on waste elimination, have an affinity with environmentally conscious green practices within organizations. Lean practices have diffused across the supply chain and to the service industry, while interest in the greening of supply chains has grown simultaneously. Linking the greening of supply chains and lean practices within a healthcare environment is relatively underexplored. This paper presents a process framework that defines specific dimensions and synergies between lean and green, to support further exploration of green lean supply chains in healthcare and particularly hospitals. In addition, the application of lean and green to hospitals explicitly brings in the third dimension of social sustainability because it focuses on the healthcare industry. The framework is applied to three cases to exemplify opportunities to green hospital processes. The process framework is also used to generate propositions for additional research in this emergent field.

Since the inception of patient portals, it has been widely assumed that portals would empower patients by increasing their participation in health decisions and subsequently reducing the burden on healthcare organizations. To investigate whether this assumption holds, we analyzed the relationship between frequency of portal use and frequency of patient clinical encounters. We found that patient portal usage is proportional to patient clinical encounters, contrary to the assumption that portal use would decrease patient encounters. Patients with poorer health tended to have more encounters and subsequently more portal usage than those with better health, who had fewer encounters, indicating a possible common factor of patients' health status. Significant differences between patients with poorer and better health status were observed for patient encounter types and portal feature usage. In addition, some portal features such as appointment scheduling, flowsheet report, medical advice, encounter details and prescription renewal were associated with fewer encounters.

OBJECTIVE:We sought to understand how patients and primary care teams use secure messaging (SM) to communicate with one another by analyzing secure message threads from 2 Department of Veterans Affairs facilities.METHODS:We coded 1000 threads of SM communication sampled from 40 primary care teams.RESULTS:Most threads (94.5%) were initiated by patients (90.4%) or caregivers (4.1%); only 5.5% were initiated by primary care team members proactively reaching out to patients. Medication renewals and refills (47.2%), scheduling requests (17.6%), medication issues (12.9%), and health issues (12.7%) were the most common patient-initiated requests, followed by referrals (7.0%), administrative issues (6.5%), test results (5.4%), test issues (5.2%), informing messages (4.9%), comments about the patient portal or SM (4.1%), appreciation (3.9%), self-reported data (2.8%), life issues (1.5%), and complaints (1.5%). Very few messages were clinically urgent (0.7%) or contained other potentially challenging content. Message threads were mostly short (2.7 messages), comprising an average of 1.35 discrete content types. A substantial proportion of issues (24.2%) did not show any evidence of being resolved through SM. Time to response and extent of resolution via SM varied by message content. Proactive SM use by teams varied, but was most often for test results (32.7%), medication-related issues (21.8%), medication renewals (16.4%), or scheduling issues (18.2%).CONCLUSIONS:The majority of messages were transactional and initiated by patients or caregivers. Not all content categories were fully addressed over SM. Further education and training for both patients and clinical teams could improve the quality and efficiency of SM communication.

To build theory about how to achieve expected benefits from a system implementation, we conducted a longitudinal study of the implementation of an electronic health record (EHR) system at a multi-site clinic using grounded theory methods and a critical realist perspective. We developed a mid-level process theory of how clinics actualize affordances arising from the implementation of an EHR. In so doing we complement the work of Markus and Silver (2008) in their application of Gibson’s Affordance Theory to the understanding of IT effects on organizations. Specifically, we replace the DeSanctis and Poole (1994) concept of appropriation with a new concept, actualization, and show how the individual level journeys of users as they actualize affordances as perceived from their various personal perspectives result in the organizational level outcomes. In building this mid-level theory, we identify the central affordances pertaining to the clinic-EHR relation and in so doing, provide an example of how to define affordances and how to conduct empirical studies using an Affordance Theory lens. Our theory should prove useful to practitioners implementing such systems.

Recruitment to randomised prevention trials is challenging, not least for intracerebral haemorrhage (ICH) associated with antithrombotic drug use. We investigated reasons for not recruiting apparently eligible patients at hospital sites that keep screening logs in the ongoing REstart or STop Antithrombotics Randomised Trial (RESTART), which seeks to determine whether to start antiplatelet drugs after ICH.

This paper presents a study of online patient portal utilization through the analysis of system logs. We analyze click data generated between August 2009 and July 2011 by 1886 users of an online patient portal. We investigate variations in utilization for Login and the top five system features (Appointment Review, Lab Tests, Medical Advice Request, Messaging and Result Component Graphing), and examine how age and gender influence these variations. Our findings indicate that the effects of age and gender on system use vary by feature, and that efficiency of use (how clicks are spread across sessions) varies across age, gender and feature. We provide a new approach for understanding system use through click data analysis utilizing system logs (an underutilized data source available to all health-care organizations), an example of how big data can help health-care organizations learn more about their patients’ utilization of patient portals.

Identifying the effects of patient portal use on patient engagement with the healthcare delivery system is an active research area. This study aims to understand the link between overall patient portal use (portal activity) and overall health system utilization (encounters) through the analyses of data logs from the patient portal and Electronic Health Record (EHR) system in a large multi-specialty group practice. Analyses of our data revealed correlations between the level of specific portal activity and encounter type. They also show portal use is clustered around other health system utilization activities. Furthermore, total encounters in a given month are predictive of future patient portal activity. Understanding such links can help health care managers plan resources to support patient needs and engagement.

The potential of patient portals to improve patient engagement and health outcomes has been discussed for more than a decade. The slow growth in patient portal adoption rates among patients and providers in the United States, despite external incentives, indicates that this is a complex issue. We examined evidence of patient portal use and effects with a focus on the pulmonary domain. We found a paucity of studies of patient portal use in pulmonary practice, and highlight gaps for future research. We also report on the experience of a pulmonary department using a patient portal to highlight the potential of these systems.

Intravenous rt-PA is an effective recanalizing treatment for ischemic stroke within 4 and half hours from its onset (Onset-to-Treatment [OTT]), with the best result seen in those treated within 90 minutes OTT. Yet few patients currently are treated in this time frame. From the standpoint of process improvement or a lean thinking perspective, there is a potential opportunity to reduce the time by eliminating non-value-added steps in each element of the stroke survival chain. The reduction in one time element does not necessarily shift the OTT under 90 minutes. Most likely, the reduction in OTT requires a coordinated approach to track and improve all elements of OTT, from the patient's ability to recognize the onset of stroke up to delivery of medication. Shortening this total time should be a considered an indicator of quality improvement in acute stroke care.

UNLABELLED:The 'Time is Brain" concept has been a major focus in the World Stroke Awareness Campaign.OBJECTIVE:We describe our experience with a Hackathon (junction of hack+marathon), a 24 hour event of innovation- and technology-based project development, focused around detecting stroke.METHOD:The Hackathon was held during a Brazilian Student's union (BRASA) congress involving students from engineering and other technological disciplines.RESULTS:Four teamscompleted the 24-hour challenge; two teams opted the stroke challenge. One team proposed improving detection using a mobile sensor Fit-Bit combined with a smart-phone to contact emergency dispatch. The other team developed a game, in which kids would play a role as a neurologist; to diagnosis stroke with objective to increase awareness.CONCLUSION:Hackathons can focus attention on innovation and improvement opportunities to support the World Stroke Campaign, as well as other campaigns to raise awareness for other health or social problems.

PURPOSE:The needs of complex patients with chronic conditions can be unpredictable and can strain resources. Exploring how tasks vary for different patients, particularly those with complex needs, can yield insights about designing better processes in healthcare. The purpose of this paper is to explore the tasks required to manage complex patients in an anticoagulation therapy context.DESIGN/METHODOLOGY/APPROACH:The authors analyzed interviews with 55 staff in six anticoagulation clinics using the Systems Engineering Initiative for Patient Safety (SEIPS) work system framework. The authors qualitatively described complex patients and their effects on care delivery.FINDINGS:Data analysis highlighted how identifying complex patients and their effect on tasks and organization, and the interactions between them was important. Managing complex patients required similar tasks as non-complex patients, but with greater frequency or more intensity and several additional tasks. After complex patients and associated patient interaction and care tasks were identified, a work system perspective was applied to explore how such tasks are integrated within clinics and the resulting implications for resource allocation.PRACTICAL IMPLICATIONS:The authors present a complex patient management framework to guide workflow design in specialty clinics, to better support high quality, effective, efficient and safe healthcare.ORIGINALITY/VALUE:The complex patient framework presented here, based on the SEIPS framework, suggests a more formal and integrated analysis be completed to provide better support for appropriate resource allocation and care coordination.