Department of Medicine 2016 Tech Challenge

New Uses of Information Technology to Advance the Missions of the Department of Medicine

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Explaining “Pioneering Care” to patients by having trainees build bridges between clinical questions and basic, translational, or clinical research.

Idea Status: 

The goal of this proposal is to collect, catalog, and disseminate the intellectual investments medical students and residents make to explain how research pioneers care for patients. During the course of almost any clinical encounter, a question will arise whose answer requires the physician to synthesize different domains of knowledge. In some cases, the answer might take on added dimensions with incorporation of how basic, clinical, or translational research contribute to or will someday affect our understanding of diseases and treatments. The people who first encounter these questions are our trainees: medical students doing an initial history and physical or residents who check in on their patients multiple times a day. The questions that emerge from interactions with patients are opportunities to educate physician and patient alike. They are the foundation of Daily Attending or Team Rounds and it is common for medical students and residents to invest significant time researching answers, exploring unfamiliar topics, and building connections between basic and clinical science. Ideally, this intellectual investment is translated to the patient so as to improve understanding, trust, and satisfaction of care.

Example: A third year medical student is asked by a patient, “What causes melanoma to develop?” In researching this question, student discovers the article published in this week’s (11/12/15) New England Journal of Medicine, “The Genetic Evolution of Melanoma from Precursor Lesions” with UCSF’s Boris Bastian as senior author. By reading the article (and perhaps others), student learns about the biology and use of sequencing to study carcinogenesis through successive genetic alterations, implication of UV radiation in initiation and progression, and impact on natural history of disease. Student teaches residents, Attending, and other team members during rounds. Student teaches patient. Student deposits question and brief summary of his/her understanding to repository. Curator of repository reviews, formats, and seeks expert opinion as needed. Feedback provided to student. Entry becomes available to others.

Tech innovation/needs: Searchable, curated, and accessible (mobile-compatible) repository of clinical questions that have summaries/answers that connect basic, translational, and/or clinical research to clinical care.

Collateral benefits: 1) Codifies an important component of the Bridges curriculum—bringing basic sciences into the clinical rotations. 2) Increases awareness of research happening at UCSF and provides new opportunities for mentorship between esearchers and trainees. 3) Increases patient awareness of research endeavors at UCSF. 

Commenting is closed.

Pagers Begone: A Proposal For a Secure, Modern, Mobile Hospital Messaging System

Idea Status: 

Pagers Begone: A Proposal For a Secure, Modern, Mobile Hospital Messaging System

There are two big problems with intra-team communication on the inpatient medicine service at UCSF hospital:

  1. It’s hard to know who is on a patient’s care team, and how to reach them. A patient’s care team is comprised of many members: the primary team, consulting teams, nurse, pharmacist, nutritionist, PT/OT/SLP, social worker, and more. The person in each role is constantly changing as shifts start and end, and sub-teams turn over. Time is wasted every day as care teams attempt to identify who its members are, and how to best contact them, since this information is not easily and consistently accessible in a single place.
  2. Communication among team members in the hospital is disjointed. Information about patients is usually passed in a 1:1 fashion between one team member and another, sometimes in the form of face-to-face conversation, but usually in a blizzard of highly inefficient one-way pages and call backs. There is no mechanism for sharing updates with the entire care team. This haphazard system can lead to confusion among team members (and patients) who possess out-of-date or inconsistent information.

Staff at UCSF should not still be using archaic technology – namely, one-way paging – to communicate with each other in the hospital. Last year, Careweb was introduced in an attempt to modernize hospital communication. While it is theoretically helpful to view a stream of recent text pages on a patient’s Careweb “wall,” there are several problems with the software: 1) the interface is clunky, 2) there is no “home page” where you can view your panel of patients, 3) you cannot open a “page” for a patient and view all associated team members and their up-to-date contact information, 4) not all team members use Careweb for paging, so there are missing voices in a given patient’s newsfeed, 5) the culture of the hospital is such that team members do not refer to patients' Careweb newsfeeds regularly, and 6) physicians are still using one-way pagers. We need to take another leap, and dispense of 1980s paging technology completely.

I propose the development of a secure, modern, mobile messaging app for use in the hospital, inspired by Slack, the popular productivity tool that has been adopted and customized by numerous cutting-edge tech companies in the Bay Area. The goal of this app is to funnel information about a patient’s care plan into a single place, where any team member can access it at any time. This will improve work efficiency and coordination of care, leading to greater patient and provider satisfaction.

The vision: All care team members, from physicians to social workers, will download the app on their smart phones and assign themselves to their patients. Team members can subscribe and unsubscribe to each patient’s channel as needed. All communication about patient care will flow through this app. When you log in, there is a list of channels. Each channel belongs to a patient, and patient channels can be organized alphabetically, by team, or by geographic location. If you click on a patient's channel, it opens and displays basic information about the patient (eg name, MRN), a list of the patient's care team members, and a dynamic group text thread. When a text message is sent, it is visible by the entire care team, which ensures everyone is on the same page – literally.

Benefits of the app:

-       Ubiquity and fluency. The vast majority of hospital staff already own a smartphone and are familiar with the touch-and-swipe interface, so there is no need to design, distribute, and educate team members about a new piece of hardware.

-       Portability. Today, physicians must respond to pages by 1) finding a phone and calling back, 2) finding a phone and sending back a numeric page, or 3) finding and logging into a computer, opening Careweb or Pagerbox, and sending back a text page. I suppose a physician could open the Careweb mobile app and send a text page from his or her phone, but I have never seen a person do this, which speaks to Careweb's failure to be adopted by hospital staff. It is worth pointing out that nurses accept phone calls only; they cannot be paged. With the mobile app described above, physicians have the option of responding to any page (including those from nurses) with a text message immediately and from any location, thus minimizing unnecessary phone calls and wasted time spent finding a phone or computer.

-       Team transparency. All team members will have visibly assigned their name to their patients, thus eliminating ambiguity and wasted time spent figuring out, for example, who a patient’s physical therapist is today, and how best to reach him or her.

-       Streamlined communication. In the hospital, the vast majority of information about patients flows through the primary intern, who must use antiquated, one-way paging technology to field multiple simultaneous requests, and transmit updates to multiple team members. A mobile app would make this job much more bearable. For example, the intern could send a single update to the entire care team with one button, and other team members could use the app to communicate directly with one another so that the intern doesn’t have to play middleman. The end result will be 1) a leaner workflow, freeing up more time for providers to spend at the bedside, and 2) enhanced coordination of care, with fewer instances of team members and patients receiving out-of-date, inconsistent information.

-       Easy transitions of care. The app would contain a simple “sign in” and “sign out” feature for day and night providers, obviating the need for pager forwarding.

 

Potential problems with the app:

-       Will it be secure? Users will log into the app with a secure username and password. Additional encryption is probably necessary (I am no tech expert), but providers already send encrypted e-mails about patient care to each others’ smartphones all the time, so it seems feasible that in 2015 we could design a secure messaging app for the purposes of streamlined hospital communication.

-       Will staff be distracted while using their personal device at work? Staff already use their personal devices at work. For example, providers use apps such as, AgileMD, Epocrates, and MDCalc every day while caring for patients in the hospital. To minimize distractions, individuals should be able to switch off noises/alerts related to personal use, and switch on noises/alerts related to professional use.

-       What if my phone runs out of battery? Most people are able to get through the day without their smartphone dying, but just in case, universal phone chargers can be strategically placed in hospital workrooms to ensure there is enough juice to keep everybody online.

-       What if there is no cell phone reception? All smartphones are WiFi enabled, so the widespread adoption of a smartphone-based messaging application would require the existence of a fast, secure, reliable WiFi connection throughout the hospital. Alternatively, there may be some way of guaranteeing non-WiFi cell phone reception in all nooks of the hospital.

-       What if I don’t have a smartphone? While most people own smartphones, those who do not, or those who have recently lost their devices, will have access to a supply of secure devices that may be distributed on a temporary basis.

-       Will there be too much information? The existence of an ongoing stream of text messages from multiple members of a patient’s care team could become overwhelming. One way to approach this problem is to ensure messages are directable (as they are on Slack); for example, before typing a message for the social worker, one could include the tag “@socialworkersname” which would alert the social worker that an incoming message is directed specifically at him.

-       What about clinical emergencies? The development of a secure electronic messaging system in the hospital would not preclude the continued existence of code pagers, or other devices designed specifically to notify housestaff of codes or other emergencies. 

Finally: this product was designed with inpatient medicine in mind, although it could potentially be applied to outpatient medicine as well.

Comments

Excellent idea and great use of contingencies.

As someone in the echo lab who spends inordinate amounts of time trying to identify the right contact for urgent results, I think this is a very important idea.

I completely support and echo the sentiments that Emily has articulated here.  As an intern myself currently, I do think that there are many problems with our current communication system that relies on outdated technology and results in significantly compromised patient care efficacy.  I wanted to highlight one part of Emily’s proposal that I think is the key part of this issue.  Emily does mention CareWeb, which is an IT solution that was started and continues to be improved here by the UCSF IT department.  While there are still ongoing interface/functionality improvements that can and will most likely be made in the near future, I think the main problem that’s being identified here is a problem of technology adoption.  I like the idea of a Slack inspired interface and I do think that there are ways that those user-friendly aspects could be incorporated into CareWeb’s functions (I’m sure the UCSF IT department is welcoming this feedback for their future version designs), but I think that what needs to be changed first here is behavior.  As long as there are care team members who continue to page from or to landlines and do not use a mobile app, we will continue to have to call and wait on inefficient landline communication.  Unfortunately, I don’t think that any new app will be able to solve this problem fully.  One might argue that the barrier to technology adoption with the current CareWeb app is large enough that it actively deters individuals from using it.  This may be true for some users.  However, I think the solution may lie in better user feedback and improvements to our existing home-grown CareWeb app instead of trying to build a new app from scratch with an IT grant.  It would be no small feat to create and maintain a secure messaging app with the desired functionalities and there have been many past and existing companies that have already attempted to provide products to meet these needs. (See one of YC’s latest startups Stitch http://techcrunch.com/2015/09/21/stitch-is-slack-for-healthcare-messaging/)

While there’s much more to consider in crafting a lasting solution, from my perspective the basic minimum conditions that would be required to allow for a more efficient/modern mobile messaging based communication system are the following:

1. All care team members must have constant access to a two-way messaging device (whether that is an Ascom phone, the careweb app on their personal phone, or the careweb app on some digital device issued by UCSF)

2. Full wireless and data service needs to be available in all parts of the hospital

3. Stop using landlines.  Landlines are fixed.  People are not and it is the waiting by the phone that is causing missed connections, missed meals, and other inefficiencies.  There can be incremental change and I would encourage those who do have the careweb app to message each other as much as possible on the app and avoid using landline communications.  (Once we have a functional mobile messaging solution with conditions 1 and 2 above, I think it would actually make sense to get ride of landlines completely.)

These conditions are necessary but by no means sufficient.  Even addressing these conditions, though, I’m sure will be a large project that will require significant due diligence and hospital bureaucratic processes.  Once we can get the infrastructure and culture right, the use of the technology will follow.

Thank you for bringing up this topic and starting this conversation.  It’s an important one that we need to have as an institution!

I love this idea as well.  To add to the careweb discussion, I think the major barrier to adoption of the smartphone version is the poor quality of the app.  I use it to send pages from my phone sometimes, however it is so slow and hard to use that I've found that is is usually faster to go find a computer and send a page from there. Whether an improvement of the existing careweb app, or development of a new app, this would be a very welcome improvement in communication in the hospital.

I inadvertently wore my pager to the airport recently and became the butt of relentless, mean-spirited mocking from the TSA agents. So this proposal would also reduce bullying.

As a VA-based clinician, how about an interface that would cut through firewalls and work equally well at all UCSF-associated campuses?

it would be great to figure out a way to make such an app work for ambulatory care as well!

For those of us who still have beeper ptsd from frequent pages this is a great idea.  It will take some education for those of us who are old and technophobic but this reads like something that would make a big impact!

Commenting is closed.

Tracking Patient-provider electronic messaging

Idea Status: 

Anecdotal evidence from discussing with Gastroenterology providers at UCSF suggests that patient-provider messaging has become a major aspect of clinical care at UCSF, taking up significant time and providing valuable service to patients. However, there is no formal requirement to provide this type of care, nor is there a mechanism to provide re-imbursement. It is clear that this type of care will continue to increase in importance and use over time. I propose a project to formally study its use, highlighting the following aspects:

1) Assess its use and changes over time. Is the amount of messaging increasing year over year, and with an estimate of the amount of time spent on patient messaging on the provider level.

2) Quantify exactly what is being done in these messages. How many  are patient generated versus physician generated? How much messaging relates to new issues that were not brought up in clinic, versus follow-up of issues addressed in clinic? Is its use replacing clinic visits or augmenting clinic visits somehow?

3) Is there a away to assess the effect of its use? Can it cut down on patient visits? Are patients more satisfied with their care that use it? Is there a correlation between its use and physician burnout? Can we estimate a cost-benefit of its use somehow? Are there improved patient outcomes with its use? Can we understand better variation between patient populations and providers and its use? Can we extrapolate how it will be used in 5 years? Can we envision a mechanism for funding its use?

Comments

would recommend examining which types of physicians (different specialists, primary care) receive / send the most mychart messages & measure time & burden across physician types. there is anecdotal evidence that women receive more mychart messages than men, for example, and may be have more satisfied patients as a result, but also may experience a heavier work-load / more burnout as well.

Recommend also assessing which patient messages are not clinical at all. When patients have close relationships with their provider, they may tend to use this portal for messaging that is more akin to standard social email than clinical medical discussions.

Ben, this is a great idea. I think that #1 and #2 are achievable NOW, if you submit a request for an Epic report here: https://ucsf.service-now.com/ess/apex_requests.do and scroll down to "APeX New/Modify Report Request". If you need help formulating the request, please let me or Sara Murray (or both of us) know. #3 is more of a research question, but if you get #1 and #2, it is going to be much easier to answer this question.

 

Looking forward to seeing how this develops!

--Raman, Sara, and the Apex team

Commenting is closed.

Apex Abbreviation Database

Idea Status: 

Database of abbreviations that live in apex.  When someone includes an abbreviation in a note, the reader can hover over the abbreviation with their mouse and see the full text of potential abbreviations.

Examples:

PCA = Patient Care Assistant, Patient-Controlled Analgesia

s/f = scheduled for

Most apex users examining patient charts know all of the abbreviations used, however forgetting an abbreviation can cause an unnecessary delay.  This database will help new healthcare professionals and students read notes quickly and facilitate transfer of care during time such as on-call rotation.  It will also help prevent misinterpretation of abbreviations, which can be dangerous as stated by the Institute for Safe Medicine Practices.

Commenting is closed.

UCSF HIPSTER: Hypertension - Innovating Personalized STrategies for Excellent Results

Idea Status: 

UCSF HIPSTER: Hypertension - Innovating Personalized STrategies for Excellent Results

In-person management of HTN poses a challenge for patients, physicians, the health system, and payers. It causes patients to incur the expense of missed work, parking and inconvenience and poses a barrier to care for a mostly asymptomatic condition.  For physicians, HTN management is often done on My Chart or by phone, as most of our providers do not have timely follow-up appointment access.  For our health system, visits for HTN reduce access for other types of patients who need evaluation and advanced testing.  Kaiser’s lauded HTN management service achieves excellent results, but employs expensive human capital (pharmacists, nurses repeatedly engaging with patients) almost exclusively to achieve their outcomes.  And for payers, office visits for HTN management is costly.  In terms of health care value, time to control and percent of patients controlled remains a challenge.  The new SPRINT trial, which will likely be incorporated into guidelines soon, will also raise the need for aggressive BP management with even greater precision, so as to avoid the complications of hypotension. 

To address these issues, it would make sense to leverage technology.  While apps and consumer medical devices can theoretically make personalized management more realizable, patient motivation to participate in self-care may be less for HTN than for more symptomatic conditions.  There is also a disconnect between smartphone app technology that can capture data and symptoms, the devices that record home BP, processes that would allow patients to communicate this information directly with their physician, and the workflow and incentives that would enable the physician’s office to act on this information.  This exposes a chasm and an opportunity in the current technology landscape to design holistic, patient-centered and physician-centered technology that makes the data actionable, personalized, and appropriate for current clinical workflows

We would like to design and pilot a portfolio of remote management programs that meet the needs of our various patients.  One example actively being designed by us will use an app and home blood pressure cuffs with an intelligent platform that engages patients ONLY when necessary, informs the care team ONLY when necessary, SIMPLIFIES communication using our own EMR, and enables SWIFT intervention by a care team. Rather than using technology extant, we are flipping the model and designing a product and workflow to fit UCSF health system and UCSF patient needs.  To do this, we have partnered with Vital Labs, Inc. and the UCSF School of Pharmacy to design a product for our needs.  Our goal is to continuously improve the technology based on our patients’ use patterns, user experience and feedback.  Technology often fails because it uses a heavy-handed approach, inundating patients with messages, texts, and tasks that are burdensome and not acted upon.  Our goal will be to continuously study the best possible prescription for BP measurement to result in the best outcome (BP at goal with minimal side effects using the most convenient medical regimen) without asking any more of our patients than we need. This rigorous evaluation can help us design an IT platform that overcomes, and doesn't create, healthcare disparities. Very preliminary assessment of an early version of the app in our clinic has shown that a diverse section of our population has been interested in adopting this type of management, including underserved populations.  Learning from this pilot, we will develop a HTN management menu to meet the myriad needs and abilities for our patients.  This may include traditional in-person visits, telephone e-visits, MyChart based communication, simple text messaging communication, and apps.  The aim is to devise HTN platforms that will enable us to prescribe technology judiciously, in just the right dose, individualized for each patient, and enabling physicians and clinics to operate with the utmost efficiency to achieve the best results.  We are collaborating with and learning from many divisions and units, including Primary Care, Nephrology, and Population Health, the CPI hub, and the CDHI, are very interested to hear from our colleagues' experiences at the VA and SFGH, and actively seek input from all corners.  We hope that our efforts will be generalizable to the broader UCSF patient community.  

Comments

Excellent proposal.  Really exciting!

This is an excellent idea. The specific charateristic of creating a system that utilizes our own EMR and reports only relevant information for the provider or the patient will make this tool unique and more helpful. Both patient and provider-centered.

This sounds like a great idea.  

This project has extraordinary potential. Looking forward to participating. 

I'm excited to see how this project shapes up!  Lots of potential to make life better for patients and providers trying to control blood pressure.

Commenting is closed.

Clinic/Academic Connection - Faculty Availability

Idea Status: 

There is a disconnect between the Academic and Clinic Patient Calendaring.

Currently Admin's don't have access to the Clinic Schedules and while some clinic schedulers have general access to faculty calendars, they cannot see up to minute changes in availability entered by Admins or Faculty.  

I'm suggesting a system that will:

  • Allow the Acamedic Assistant view and/or access to the Clinic Schedule
  • Allow the Clinic Scheduler, CRC's view and/or access to the Faculty Schedule

or 

  • Have a shared calendaring system for the Admin and Clinic scheduler created that will assist clinic scheduler when trying to determine availability of Faculty outside of scheduled Clinic times and keep the Admin up to date as well.

Suggestion for the program: Precoded abbreviations for each scheduling notification (Example: OOO - Out of Office, OOC - Out of Country, PTO - Paid Time Off, CPA - Clinic Patient Appt, TEL- Conference Call, UCM - UCSF Meeting, OFM -Offsite Meeting, PER - Personal Time)

 

Commenting is closed.

Crowdfunding Research

Idea Status: 

Tech Challenge

Problems:  as highlighted via https://www.ucsf.edu/news/2015/06/130511/science-interrupted

1)      The buying power of the NIH dropped by ~$5 billion between 2003 and 2013 due to inflation.

2)      Paylines are 10%-14% for NIH dropping from 22% a decade ago

Solution:  Let’s crowdfund research.

Proposal:  Create a program to allow investigators to directly solicit crowdfunding support for their research projects.   Similar to Indiegogo and Kickstarter but for UCSF vetted scientific research.

This is a program that will supplement research support for investigators via a comprehensive crowdfunding platform.  This will involve a combination of mentorship and scientific advisory from senior researchers, crowdfunding from users and industry/venture capital, support from Department of Medicine (DOM) divisions, discounts with UCSF campus life for merchandise, marketing via UCSF branding, and other stakeholders.  A DOM crowdfunding platform will also provide a social networking component for investigators to provide updates on their research directly to funders as well as provide contact information for their labs via social media (twitter, facebook, instagram, linkedin, etc.).  These updates increase the potential for additional support after initial funding has been completed and increase visibility and transparency for labs.

Process:

1)      Investigators work with their chiefs/mentors to put together a brief one page proposal for posting to the DOM crowdfunding page.  They then upload their research proposal to the page for review.

2)      Submissions are reviewed by a DOM committee (e.g. senior investigators, industry experts, UCSF DOM leadership, DOM strategic management) for appropriateness and viability for crowdfunding.

3)      Accepted proposals then receive design and video support from DOM to create a unique crowdfunding page on the DOM platform.  Similar to https://www.kickstarter.com/help/handbook.  They also receive either matching division support or discounts to UCSF DOM merchandise for different tiers of pledged support (unique research t-shirt for $35 pledge, unique hat for $50 pledge, etc.)  This is subsidized by UCSF Campus Life who can assist with design and may provide close to at-cost pricing.

4)      If funding level is hit, the project will be funded and funds will be set up as unique gift accounts and used in support of the PI’s research (up to 10% for salary support).  A 5% gift account fee can be assessed.

Benefits:

1)      Benefits for an individual funder?

  1. Funds will be raised via a non-profit entity and will be tax deductible.  Also unique merchandize like t-shirts, pins, etc., that are associated with the research labs.  (e.g. #SmithCancerLab)
  2. Benefits of putting funds directly into research without exorbitant overhead costs as well as knowing that the dollars will go to a world-class researcher whose work and potential for success has been vetted by others at UCSF.

2)      Benefits for an industry/VC funder?

  1. In addition to potential tax breaks, industry contributors get a chance to invest in the research of investigators who may one day take their research private.  Downstream, these industry/VC funders will have an early association with investigators who may wish to collaborate with the same industry partners who helped support their research careers.

3)      Benefits for PI?

  1. Funding and exposure for research.
  2. A platform for future funding as well as potential collaboration from other researchers
  3. Potential for higher level collaboration with industry/VC as research progresses.
  4. Creates a mechanism for PIs to solicit direct funding for their research from friends/family/others.

4)      Benefits for DOM/UCSF?

  1. Increased funding for investigators
  2. Visibility for specific research
  3. Social networking for research
  4. Leverages positives of the tech and social awareness climate and the current desire for innovation while ensuring research integrity

Draft budget:

$15k website and platform

$15-20k video production costs (for individual submissions)

$15k mobile

$10k marketing

$10k HIPAA compliant hosting and basic support for one year

Comments

Thanks for this excellent idea. Can you detail how this is different from the existing UCSF crowdfunding options:

1.) https://crowdfund.ucsf.edu

2.) https://www.indiegogo.com/partners/UCSF

3.) https://www.crowdrise.com/ucsf

Thanks!

Hi Mitchell,

Certainly.  The other platforms seem somewhat general and are not specifically for medical research.  Additionally, it doesn't seem as if proposals put forth on those sites undergo review from research experts before being posted.  The platform I'm proposing is specific to the research community and the proposals submitted will be first vetted by a research council before the information is then broken down in layperson's terms for posting (we'd work with approved submissions to try to break down the science and essentially use whiteboard animation/other media to explain what the idea is to the public).  This is similar to experiment.com but even that site does not have a review before proposals are posted to the site.  By creating our platform in-house and coupling it with both the UCSF Medicine brand and the expertise of our own research council, donors/funders/industry will know that proposals on the site have been vetted and are being put forth after careful review.  I think they will be more likely to contribute in that instance since they won't have a page full of proposals to look at, but instead ~5 initiatives that have the backing of the Department of Medicine.  I think if we can show show proof of concept with a DOM-centric page, we can later shift the focus onto the division websites and embad platfoms there and then have the highest trending proposals pull onto the main DOM site.  Hope this helps!

Commenting is closed.

Discharge "To-Do's" Autopopulated in PCP Notes

Idea Status: 

Among the most important components of the hospital discharge summary is the section titled "Follow-up Needs for the Primary Care Physician." This contains specific "to-do's" such as "follow up blood culture results" or "check potassium level in 1 week." These items are often crucial continuations of care needed to close the loop on productive and high-quality hospitalizations. However, they are buried in the bottom of a several page-long discharge summary, making them less likely to be seen and acted on by PCP's. 

For patients who are hospitalized at UCSF and follow up with PCP's on EPIC, there's a better way. Primary care follow up needs can be put in a separate section of the discharge summary - a user-friendly box - that will link directly into primary care notes using a smart phrase. Here's how it works step-by-step:

1. Create a required Primary Care Follow-up box in the inpatient Discharge activity

2. Create a smart phrase that links to the text in this box

3. Encourage PCP's to include the smart phrase in their post-hospitalization note templates

4. To-do's will automatically populate into the Assessment and Plan of primary care notes, making them more likely to be seen and completed.

This change is technically feasible, has the potential to improve patient care transitions, and requires significantly fewer clicks for PCP's, while requiring only one additional click for discharging physicians. 

Comments

would also recommend moving the to do for follow-up section to the top of the discharge summary. most of us do read and scroll down, but would appreciate seeing this at the beginning when we are seeing our patients for post-discharge follow-up.

We are building a cardiology outpatient recovery (COR) transitions clinic slated to open in the spring.  In addition to being used in primary care, this "to-do" list would be very helpful to the cardiology clinic provider who will be needing to follow up on resident-identified follow up issues.  Nice idea.

Hi Timothy,

We think this is a great idea and something that would be worth discussing with our build team.  Why don't you submit an AC3 ticket for modification of the discharge summary template (needs to be done in collaboration with a SME like Brad Monash) and we can look into ways to make this work.

Best,

--Sara, Raman, and the APeX team

Great idea!  If you're still refining this idea, would be super helpful to also build in an automatic link to or autopopulate function for those unexpected, incidental radiology findings / recommendations for follow-up that collect during a hospital admission and the discharge to do box e.g. "8mm nodule on chest CT, recommend repeat chest CT in 3-6 months"  

These are very high risk of falling off the to-do list on discharge summaries, especially for long, complex admissions.

Commenting is closed.

Ambulatory Care Tailored-assessments Across Literacy and Language (ACT for ALL)

Idea Status: 

The Problem. Ambulatory physicians utilize many different types of standardized assessments, ranging from depression screening, to functional pain assessments for patients on opiates, to incontinence and benign prostatic hypertrophy screening for older women and men. Many of these assessments are used in both primary care and specialty practice. Which assessments are done at a given visit depends on the specific patient’s demographics (e.g., age, sex), when their last screening was and if they are due for another, and sometimes the patient’s diagnoses or medications.

The Barriers. There are several barriers to conducting timely, standardized, assessments tailored to the patient’s needs. 1. Currently this requires an individual – often the physician – to investigate and note that the patient should have a particular assessment. 2) These assessments are often time consuming to conduct in practice. 3) Many assessments are available in paper instruments for patients to complete themselves, but one-in-four patients have inadequate health literacy, and assessments are not always available in the patient’s preferred language. 4) The results of the assessment require physicians to document them in the note or scan them into APeX, and then they are not easily found or tracked.

The Solution. A platform that allows information to be pulled from APeX (e.g., demographics, relevant medications or diagnoses), and sent in real-time to a secure device which can provide low-literacy, multi-lingual, video-doctor directed assessments to the patient while they are waiting to see their doctor. The tablet will then integrate with the patient’s visit encounter to send the assessment information into a flowsheet or the progress note so that the physician can see the results and act on them. Each assessment would also be linked to an educational video for those patients who identify a problem (e.g. for stress incontinence a video about kegel exercises, or for depression an introduction to evidence based treatments), which the patient can view before or after the visit depending on timing. These videos could also be made available on-line for patients with a secure password that would be generated by their answers to the assessment.

Such a secure, low-literacy, multi-lingual application already exists. It is called Phrazer and is being used in other settings already (emergency department, inpatient), but has not been used in ambulatory care. http://www.myphrazer.com/ The company that has developed Phrazer is interested in partnering to develop content for ambulatory use and clinical integration.

Needs. Although the application exists, there is still need for the following: 1) UCSF to develop a platform to pull information from APeX and push it to another application for tailoring of assessments – such an platform would be useful for other applications in the future; 2) selection of best practice standardized assessments that will be useful for the largest number and range of patients presenting to primary care, and that would also be useful in various specialty care; 3) content of video-doctor educational modules with translations and bilingual-bicultural video-doctors in UCSF’s main non-English languages; 4) integration to push assessment information into APeX; 5) workflow assessments for use in clinical practice; 6) pilot use in practice with assessment of patient, staff, physician acceptability and perception of usefulness, measurement of process improvement metrics. 

Comments

This has great potential to ensure that all of our patients benefit from the evidence-based assessments and reduce barriers to using them in busy ambulatory practices. The implications for improving care are great!

This is a great idea that uses technology to improve care for patients who may be vulnerable because of low health-literacy or language barriers.  Many typical digital health tools focus on quantified selfers or the worried-well - this project tries to reach vulnerable populations in real-world clinical settings that could improve patient education and help their providers obtain and document assessments that would otherwise be too costly to obtain.  Good luck!

Commenting is closed.

The beeper that beeps back

Idea Status: 

Do we have the technology to develop a beeper/device that has the capability to text back to nurses voalte phones?  It would obviate the need to reach out for a phone or a computer every time a doctor is paged, and would improve communication among team members. 

Comments

This is a great idea Carla! Voalte itself has that capability, so we should chat if/after the Voalte platform is upgraded, as that is the pre-requisite for making this work. 

Commenting is closed.

iMOVE: inpatient Mobility Optimization program for Vitality and hEalth

Idea Status: 

We propose the use of activity trackers (such as 'Fitbits') in an inpatient center to encourage patient mobility and more precisely measure the amount and types of activities patients are performing. De-identified data from these activity trackers would be presented electronically both to providers/staff and to patients in order to motivate patients and to allow staff to see patients that were due for a mobilization session. 

This project could use off-the-shelf technology with some minor modifications to enable it to be used in a health care setting and to enable data to be collected and displayed in a centralized location.

Our desired outcomes would be increased mobility of inpatients, stable level of functionality at discharge, decreased length of stay, decreased falls, and increased rate of discharge to home.

Background

As the population of hospitalized patients ages we will increasingly encounter patients with functional limitations of at least 1 ADL upon admission (1). During hospitalization these patients are vulnerable to the consequences of hospitalization and decreased mobility such as pressure ulcers, delirium, decrease in muscle mass, and ultimately an additional decline in their functional status (1).

In a study of patients aged 70 and older and with low or intermediate levels of mobility 29% had a decline in at least one ADL at discharge and 22% were discharged to a new institutional living situation (2).

Current Research

The STRIDE program at the Durham VA (3) has demonstrated that an activity program can lead to a decreased rate of discharge to skilled nursing facilities. A challenge that this program faced was monitoring and encouraging activity. There is some evidence that activity trackers can lead to a change in behavior and an increase in frequency and amount of activity.

Conclusion
Our innovation would be to bring this technology to the inpatient setting and display mobilization data in real time and in a centralized location. Receiving this grant would allow us to purchase equipment and enable staff to implement this project. This would then hopefully lead to improved functionality and health of our patients.

References

1.  Kleinpell RM, Fletcher K, Jennings BM. Reducing Functional Decline in Hospitalized Elderly. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 11. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2629/

2.  Brown, C. J., Friedkin, R. J. and Inouye, S. K. (2004), Prevalence and Outcomes of Low Mobility in Hospitalized Older Patients. Journal of the American Geriatrics Society, 52: 1263–1270. doi: 10.1111/j.1532-5415.2004.52354.x

3.  Hastings, S. Nicole, Sloane, Richard, Morey, Miriam C.,Pavon, Juliessa M.,Hoenig, Helen, Assisted Early Mobility for Hospitalized Older Veterans: Preliminary Data from the STRIDE Program, J Am Geriatr Soc 62:2180–2184, 2014

Comments

Great idea

what an awesome way to track activity

Maybe good to send them home also for outpatient compliance measurement

 

This is a very important project to change the trajectory of our patients!  Highly needed.

Sleep tracking is also a possibility with these types of devices. It would also be interesting to evaluate this and feed back to staff in order to reduce patient disturbances at night.

This proposal is a fanastic, patient-centered approach that focuses on encouraging healthy behaviors and brings the theme of salutogenesis (a theme that the new Bridges curriculum holds as a pillar of medicine, but one which we rarely see reinforced in the inpatient setting) to life.  Further, the loss of functional status during inpatient stays is particularly important to consider in a time when community nursing home placement is increasingly challenging, particularly for veterans.  Excited about the possibilities to bring this positive intervention to our patients here at the VA!

This proposal is a fanastic, patient-centered approach that focuses on encouraging healthy behaviors and brings the theme of salutogenesis (a theme that the new Bridges curriculum holds as a pillar of medicine, but one which we rarely see reinforced in the inpatient setting) to life.  Further, the loss of functional status during inpatient stays is particularly important to consider in a time when community nursing home placement is increasingly challenging, particularly for veterans.  Excited about the possibility of bringing this positive intervention to our patients here at the VA!

Great, innovative proposal the improve the care of our  patients.

Great, innovative proposal to improve the care of our  patients.

Would love to see this happen! I bet the patients will love it too...

Great project (and acronym!) - also would be interesting to measure outcomes in specific populations such as pneumonia patients, where early mobility has been shown to decrease length of stay

Commenting is closed.

Video-based simulation to enhance communication between generalist and specialist providers for specialty care consultations

Idea Status: 

Technology is increasingly proposed as a more efficient conduit to facilitate communication between generalist and specialist providers. However, little is understood about how to use these technologies to improve provider-to-provider collaboration and communication regarding specialist consultations. Electronic portals (e.g., EPIC, CPRS) serve an important role in enhancing connectivity between providers across service lines, but greater connectivity does not necessarily translate into greater collaboration.

One fundamental problem when consulting a specialist is that while generalists may have broad knowledge of patient psychosocial context, they may not know how to concisely formulate a specialty care consultation question to communicate the range of medical, psychological, and social issues when dealing with complex chronic illnesses. Our team has video-recorded over 127 hours of generalist-specialist consultations using a video telemedicine interface. Using specialized software, we developed an algorithm to analyze the consultation into time-encoded components of the consultation process, such as patient case presentation, presentation of the primary consult question, case discussion and negotiated care decision making, and social talk between providers.

Our findings indicate that when making a specialty referral, generalists are faced with two problems. First, some generalists are unaware of the required prerequisites, such as documentation of diagnostic results such as labs, imaging, etc. to document a possible specialty care problem prior to referral. Relatedly, because of their broad training, generalists may not be able to pose specific and concise questions. As a result, consultation requests can be administratively delayed or rejected or misunderstood, which can compromise patient safety, timely response to patient concerns, and effective care coordination Second, generalist providers can sometimes be intimidated by specialty providers, which can contribute to strained interpersonal and working relationships.

To remedy these problems, we propose an interactive training intervention using the Conversation Analytic Role-play Method (CARM), a communication skills training and assessment method. CARM interventions expand participants’ knowledge of effective and ineffective communication and enable participants to practice communication techniques to solve problems they may encounter in actual situations. CARM uses a novel simulation technique as the primary educational strategy in which audio or, preferably, video recordings are shown and reviewed to slow down real-time events with the goals of examining the communication process in forensic detail, discussing possible responses, and practicing new communication skills in a group format.

We will use CARM to develop an intervention with our previously video recorded consultations and the resulting analysis. The overall goals of the intervention will be, first, to educate providers about effective and ineffective communication strategies when referring a patient to specialty care, and second, to give generalist and specialist providers an opportunity for social interaction during a shared didactic experience. These combined goals will address the problems identified in our research to date. We anticipate developing between three and five training modules of different durations from 15 to 30 minutes in length that can be disseminated in person and/or via video teleconference to facilitate busy provider participation. Training sessions will combine didactic and interactive components. The didactic component will use anonymized segments of video data to illustrate key principles of effective and ineffective clinical communication. Interactive components will ask participants to role-play as both a group and as individuals to practice the communication skills introduced and discussed during the didactic component. Participants will be a combination of generalist and specialist providers.

We will evaluate our intervention using a mixed methods approach. Quantitatively, we imagine using a basic pre-post design in which provider participants’ knowledge, attitudes, and beliefs are measured using surveys. Qualitatively, we imagine conducting brief semi-structured interviews with generalist-specialist participants. Together, the quantitative and qualitative data will be used to gauge acceptability of the intervention and to assess changes in 1) specificity, concision, and clarity in consult communication; and 2) interpersonal relationship between generalist and specialist providers. The evaluation will be guided by the Knowledge to Action framework (Graham, Logan, Harrison, et al. 2006), a theory-based conceptual model used to help translate knowledge for continuing health professionals' education. This framework has been successfully used both to understand and to influence sustainable change in a range of clinical practice settings. 

This proposed project leverages our previously collected data in order to improve communication effectiveness between generalist and specialist providers when requesting consultation. The intervention provides participants with specific communication tools to address a high-stakes work-related task for which both generalist and specialist providers have a substantial professional interest. Simultaneously, the intervention supplies generalist and specialist providers an opportunity for a shared experience, which has the potential to facilitate increased interpersonal connection. We believe this proposal has the potential to improve the coordination of care between providers, timely access to specialty care services, and, ultimately, the overall quality of patient care.

Commenting is closed.

Leveraging telehealth for Resident and Fellow Education for homebound patients

Idea Status: 

There is increasing interest in the use of telehealth initiatives nationally.  Simultaneously, Medicare and other payors are increasingly recognizing that home-based care can be effective, cost-saving, and more person and family centered.  To date, opportunities for trainees to learn about home-based care are limited by current funding mechanisms.  For example, the primary care exception that allows residents to see patients in clinic and bill medicare, does not apply to the home setting. 

At UCSF, Primary care residents and fellows have had opportunities to see patients at home on a very limited basis via the UCSF Division of Geriatrics Care at Home Program.  However, this opportunity has been limited by lack of funding for faculty oversight, and most of the visits are done without capability for attendings to precept the visit LIVE.  The use of telehealth for trainee education could help provide funding for faculty oversight while also enriching the trainee experience by being able to have "live" precepting.  If funded, this opportunity could be avaiable starting with Internal Medicine Residents, Geriatrics Fellows, Nurse Practitioner students, and Palliative Care fellows.  If successful, it could also be easily expanded to include other disciplines.  For example, live telehealth consults for homebound patients who cannot otherwise see specialists, for example, orthopaedics.

This idea is innovative, interdisciplinary, feasible and has the potential to add a new dimension to our education mission, our trainees needs, and help provide person and family centered care. 

 

 

 

 

Comments

Absolutely agree and support. While I'm mindful that CMS is likely concerned about abuse of primary care exception, they must also recognize that their Medicare population is growing larger which means a growing population of homebound adults who still need care. We not only need to provide this care but to teach our learners how to provide competent and comprehensive care in the home. By restricting the primary care exception to bricks-and-mortar clinics, CMS is inherently limiting the competence of its future health care workforce. Telehealtlh is an answer to these restrictions. DOM/UC Medical Center can take a forward step by recognizing and developing a reimbursement strategy for tele-precepted home visits. On broader scale, by showing we can effectively train learners and provide care, we can better advocate for CMS to change their rulings. 

Sounds like a win-win.   Trainees see get experience with house calls and faculty/UCSF get funded to do so.   

Great idea that creatively allows faculty with geriatric expertise to precept more trainees during home visits.  This will enhance trainee skills in home care and geriatrics and improve care for homebound older adults.

From the perspective of a trainee, this sounds like a fantastic idea that would facilitate the educational experience of the residents and fellows while remaining relatively burdenless. It would also make more transparent for the patient the whole process of "precepting".

This is a strong proposal.  It would help secure our  institution as leaders in implementing what will soon become a common way to provide healthcare for populations.  It allows for multiple discplines within the health center to "touch" patients in a low-cost, interdisciplinary way.  Nurses, social worker, physicians, and others could be taught to provide care in the home setting, extending the reach beyond the clinic and hospital to provide a safe continuum of care thus preparing UCSF for the emerging ACO market and Medicare Advantage plans.

As a trainee, I am excited about this opportunity to participate in telemedicine to reach home limited patients. We currently do not have any training in telemedicine as a part of our residency and this would be a forward-thinking addition to our program. The opportunity for live preceptorship would be key to the educational value of the home based primary care experience for residents as well, so I'm glad to see that has been included in the proposal.  

Wonderful idea, this would strongly enhance the skills of trainees while improving the productivity of supervising faculty several-fold. Very feasible. It could also be a "foot/tablet in the door" that creates a model for doing more sophisticated, as-needed, in-home consulting to help maintain complex patients at home whenever possible.

Commenting is closed.

Covering provider appointment notifications on APeX

Idea Status: 

We propose a notification system via the APeX staff message/ADT interface to give Resident Physician PCPs information regarding their patients' appointments with covering providers in DGIM. 

Background of the Proposal

  • The General Medicine Clinic at Mount Zion consists of 10 internal medicine (IM) resident and attending teams IM residents have, on average, 2-4 half day clinic sessions per month, meaning most patients assigned a resident PCP see other providers for acute appointments and, sometimes, follow up appointments.
  • APeX does not currently notify the IM resident PCP if one of her/his patients is scheduled with a covering DGIM provider.

 Proposed Change

  • Similar to the way PCPs receive Hospitalization notices from the ADT system, we propose alerting resident physician PCPs via an inbasket message when their patients are scheduled for a DGIM appointment.
  • This message would include metadata from the scheduling event including chief complaint and the time/date of upcoming appointment.
  • The IM resident PCP would be able to then message the covering MD about any background information or outstanding issues.

Aim

  • These acute appointment notifications will improve continuity of care between PCP and covering providers, reduce medical errors, and increase patient satisfaction

Potential Measurements to Test Effectiveness

  • Resident physicians within DGIM could be surveyed for the following responses:
  1. Awareness of the new functionality
  2. PCPs’ utilization of option to message covering providers
  3. If PCPs messaged a covering provider, the type of information provided in message
  4. Likert scale measuring effectiveness of provider to provider communication and the perceived impact on continuity of care

Commenting is closed.

Measuring quality in the "transitional chaos"

Idea Status: 

Physician note-writing is an opportunity to teach, share ideas, and solidify clinical decision-making.  Yet as billing requirements and copy-paste functionality have increased in recent years, the utility of writing and reading these notes has declined steeply.  In addition to the dehumanizing "tyranny of clicks and auto-populated fields," (Rosenbaum, "Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine"; N Engl J Med 2015; Oct 2015; 373:1585-1588), we have all experienced the embarrassment of reading notes riddled with glaring, late night errors that become a permanent part of the medical record.  The bulkiness of auto-populated information in notes also reduces the reliance on written notes for inpatient communication.  While in-person verbal communication is critically important, the EHR is not meeting its potential as a reliable account of patient care, and the burden of the "tyranny of clicks" is detracting from our ability to produce notes that are as meaningful as possible.  Furthermore, the extent to which errors in notes contribute to poor patient outcomes at our center is not known.  In order to improve medical education, increase efficiency in medical care, and reduce avoidable errors, there is an urgent need to re-evaluate how we compose our inpatient progress and consult notes.

This proposal has three main goalsFirst, we will track “typographical” errors in notes, comparing anonymized data by author type, service, time of day signed, and total number of notes written by that author per day. We hypothesize that errors will be prevalent, and that the number of errors will be higher among individuals who write many notes per day and sign their notes later in the day.

Second, we will characterize the teaching value of notes (graded by specific criteria) across services.  We hypothesize that the teaching value of notes will be inversely proportional to the bulkiness of excess information contained in auto-populated fields.

Finally, we will perform rigorous anonymous provider surveys to determine their trust in the EHR documentation.  We hypothesize that trust in the accuracy of EHR documentation is low, and that the majority of providers will view EHR documentation as a hindrance to rather than an aide for patient care.

These initial goals will lay the foundation for an intervention in which we will test two methods of note writing - free text versus autopopulated - and compare outcomes of documentation accuracy, trainee learning, provider satisfaction, and patient care.

Detailed Methods

Goal 1.  To track errors in notes.  A smart programmer (name TBD) will develop code to identify inconsistencies and errors in notes.  For example, when physical exams describe inconsistent findings that can never co-exist (for example, "obtunded" in the same exam as "neurologic exam nonfocal"); failure of a treatment or hospital day to be updated (same day "X out of X" of antibiotics listed for several days in a row); or list medications that have been discontinued (this will be complicated but should be able to be cross-referenced between A/P section and active med list on that day's note). The scope of errors in medical documentation will thus be defined as a starting point.

Goal 2. To characterize the teaching value of notes.  The burden of charting has taken away the joy of an important purpose of writing notes - reflecting on the patient and describing one's thinking process in words.  We will take a sample of notes from different author types (including consultants) and de-identify the author and patient information, then subject the notes to a grading system by which the teaching value of the notes is measured.  The criteria will include differential diagnoses, literature review, and descriptions of clinical reasoning.

Goal 3.  To assess provider trust in the EMR.  Using surveys targeted for different types of providers, we will assess the ways in which EMR notes are used – for verifying recommendations, understanding patients, and confirming plans.  We will solicit providers’ main sources of dissatisfaction with EMR documentation and their ideas for improvement – addressing “the third problem: many clinicians know what they want — but haven't been asked” (Rosenbaum 2015).

Achieving these goals has the immediate potential to improve clinical service and education.  Once the systems for tracking these errors and measuring teaching value have been developed, the project will be scalable beyond UCSF to other academic teaching hospitals that rely on EPIC.  The time frame for implementation will be feasible prior to December 31, 2016 as our goals are well-circumscribed and will be focused on inpatient documentation only.  Eventually, the intervention stage of the project will allow UCSF to be a pioneer in testing new methods of ensuring quality patient care through note-writing and transcending the drive for physician notes to be the sole source of billing documentation.

Important questions

What about outpatient notes?  This is a critical area with its own pitfalls and opportunities and thus will require its own plan for assessment and implementation, which can be addressed at a later time.  The scope of the current proposal is strictly for inpatient notes.

What if people start paying more attention to their notes because they know this is going on?  That would be great!  It would be a terrific outcome of the project and would not affect the overall purpose, which is to enhance the meaning and teaching value of the documentation included in the EMR.

What about billing???  This intervention will be the first step toward our combating the problem that a focus on billing has taken over our focus on patient care.  We have the opportunity to be at the forefront of necessary reform of the medical system causing "enduring harm," job dissatisfaction, and poor patient care.  This proposal will establish our leadership in implementing measures to ensure that physicians and our patients survive the “transitional chaos” successfully.

Commenting is closed.

Housestaff location reporter

Idea Status: 

Efforts to improve physician education and patient safety often start by gathering data about when and where housestaff are engaging in direct patient care, administrative work, and learning activities. But the information from these self- or observer-reporting surveys is inherently unreliable, meaning that any conclusions based on its interpretation are faulty, and interventions to improve housestaff experience are unlikely to succeed.

This proposal entails using existing technology that monitors the 3-dimensional position of a tracking chip to perform anonymized real-time analysis of Medicine housestaff location. In the initial phase, data on location will be quantified, including time spent in patient rooms, work areas, and conferences. This information will then be used to design prospective controlled trials of interventions aimed at improving housestaff efficiency, increasing time for learning, and enhancing patient safety.

Commenting is closed.

Creation of a learner driven GME EPA assessment system for internal medicine residency and fellowship programs.

Idea Status: 

Proposal Overview:

Assessment of graduate medical education (GME) trainees is a high priority of training programs.  Training program directors must be able to certify that graduates are able to practice independently in their respective specialty/subspecialty.   Most Accreditation Council for  Graduate Medical Education (ACGME) programs, including the UCSF Department of Medicine (DOM) ACGME programs,  have an assessment system that is designed to report milestone assessments to the ACGME and the organization responsible for certifying individuals (such as the American Board of Internal Medicine).   Milestone assessments are assigned by programs for faculty or other supervising personnel to complete and return to the program for review by Clinical Competency Committees (CCCs).  The relevance of the milestones to the complexity of physicianship as well as trainee and faculty engagement with the assessment process has presented challenges to collecting, analyzing and reporting the clinical competence of trainees for DOM training programs.  We seek to create a novel, learner-driven GME assessment system, using Entrustable Professional Assessments (EPAs) in a newly developed information system that seeks to better assess trainee performance while empowering trainees to actively manage their own assessment process. 

Specific Aims:

1-     Design and implement an information system for all Department of Medicine educational programs that will collect and display trainee assessment data with customized views to allow trainees, advisors and competency committees to effectively assess trainee performance. 

2-     Change the culture of trainee assessment from program-driven to trainee-driven by enabling learners to pro-actively solicit faculty assessment in areas of need, monitor their progress with meeting assessment goals and to control the release of designated assessable elements to the clinical competency committee under the guidance of their faculty advisor. 

Background and Significance:

Various frameworks have evolved over the years to guide how to assess and report the competence of trainees.  The transition to a philosophy of assessing trainee outcomes began in 1999 when the ACGME introduced the six core competencies (patient care, medical knowledge, systems-based practice, practice-based learning, communication and professionalism).  The introduction of the Next Accreditation System (NAS) evolved these concepts to include milestones as subsections of the core competencies.  The internal medicine community began with 142 educational milestones which were subsequently reduced to 22 sub-competencies embedded in the original 6 ACGME competency domains.   (2)

In recognition of the limitations of the milestone-based assessment process an alternative approach to assessment uses EPAs as a framework for assessing competence.  EPAs reflect the degree of mastery of professional tasks that together constitute the work of a profession. (3)  Successfully performing EPAs requires abilities in multiple competencies.  Using EPAs for assessment recognizes that professional tasks are complex and provides a holistic view of the successful acquisition of professional skills. 

Current UCSF DOM Assessment Strategy:

In response to this rapidly changing landscape our current assessment strategy utilizes both milestone and EPA based systems to assess our trainees.  Our primary modality of assessment links specific milestones to trainee rotations and are sumatively assessed by faculty utilizing the E*value platform system.  Our programs may deploy different tools (global assessments, procedure observations, 360’s, chart stimulated recall, qualitative comments) to assess their program specific milestones but most programs depend upon observational methods to record the initial milestone assessment. Clinical competency committees (CCCs) then meet to determine the summative milestone score that is reported to the ACGME and the ABIM.

Currently, there are a few EPAs in use in certain programs (Internal Medicine, Geriatrics, and Hematology/Oncology) that are recorded in a Qualtrics survey platform but those data are hard to collate in a meaningful way for use by the CCC. Therefore, CCCs are largely dependent upon the milestone scores obtained from direct faculty observations, a process that has many limitations. .

Analysis of DOM Assessment Strategy:

Program CCCs are reporting issues with their milestone assessment processes that have been in effect since AY2013-14 for the internal medicine residency program and AY2014-15 for the fellowship programs.  First, compliance with completing the assessments is poor; across the DOM training programs, the overall compliance of assigned evaluations is initially only 50%.  Much administrative time is spent trying to get completed evaluations to the required 70% level and often program leadership has to step in to improve faculty compliance.  Reasons faculty cite for their challenges in completing assessments is “assessment fatigue” caused by multiple end of the month evaluations being due simultaneously, the need to assess as many as 22 milestones and overall frustration with the E*value platform.  Faculty also state that they have learned to ignore or delete automatic email assessment reminders from E*value, further complicating compliance with our evaluation process. Faculty also states that direct requests from trainees for feedback are harder to ignore due to the personal connection of the request. 

Second, the quality of the assessments is also in question.  CCCs are now often basing their judgments on insufficient numeric scores within each milestone category. This has led our CCC to become concerned about whether we are fully able to assess trainee’s performances.  Similarly, our CCC is unable to effectively identify areas of concern for struggling trainees, preventing appropriate remediation efforts. 

In an effort to promote EPA based assessment, the internal medicine residency began exploring the use of an EPA-based assessment system in 2013.  In 2013-4 we utilized a Delphi method to implement a group of 8 EPAs to help make our assessments more activity specific. (Table 1)  We also identified twenty-two subsequent EPAs with at least 80% participant agreement that can serve to guide our future expansion of this network. (6) 

 

Table 1.  Current EPAs housed on Qualtrics Platform

Acute Care EPA

Clinic Post-Discharge EPA

Code Leadership EPA

Discharge summary EPA

Four habits clinic survey

Multidisciplinary Rounds Inpatient Feedback

Rounds Observation EPA

Serious Illness Communication

Although these and future EPAs contain of a robust menu of assessment parameters, we have been unable to implement them in a meaningful manner due to several limitations with our assessment technology as well as our inability to create a trainee-centered interactive assessment platform.  Table 2 outlines our efforts at implementation thus far. 

Table 2.  Timeline of EPA Implementation efforts

Platform Used

System Advantages

Problems with Implementation

Mahara Portfolio System

Trainees log own assessment data.

Captures wide range of data.

Trainees release data for feedback.

Unwieldy to add data.

Inability of faculty to track progress.

MyFolio System

Potential for single data platform.

Ease of expansion to new EPAs.

E*value/MyFolio platform communication.

Qualtrics

HIPPA compliant.

Easy to use, edit, summarize data.

Free use for UCSF.

Data management.

Unable to summarize for CCC.

Lack of interconnectivity with current assessment platform.

Unable to utilize quickly on handheld device.

 

Vision for Future Assessment Process:

While learning about our aforementioned concerns regarding assessment amongst our faculty and CCC, we have been engaging our trainees to formulate our future assessment process.  Eight focus groups with a total of approximately 100 residents and fellows have been conducted over the last three years.  Several themes have emerged from these focus groups that match concerns voiced by resident trainees across the country when there is inadequate supervision or feedback.  (4-5)  These themes are summarized in Table 3.

Table 3.  Trainee themes from assessment focus groups.

Theme #1

Trainee assessment that depends on summative feedback from end of rotation (i.e. milestone-based assessments) lack specificity to enable trainees to improve their professional practice.  Trainees would prefer more timely, qualitative, in-person and practice based feedback to help them grow professionally.

Theme #2

Current assessment tools create scores and comments that are difficult for residents to understand or to access to help them follow their progress in real-time. 

Theme #3

With the advent of the Clinical Competency Committees (CCC) mandated by the ACGME, trainees feel there is a lack of transparency or control over their own assessments leading to mistrust of the assessment system.

Theme #4

The current culture in our residency and fellowship programs does not facilitate constant, clear and continuous feedback from faculty to trainees.  Trainees feel this acutely and often feel criticized when receiving anything less than superlative feedback from faculty.

 

To take an initial step of addressing these themes we began a two month pilot project where trainees actively solicit EPA activity-based feedback from faculty or other professional staff.  These evaluations are completely resident driven and are collected in Qualtrics. This “proof of concept” pilot enables us to examine the rates of completion of EPAs, willingness of residents to participate in the process and their satisfaction with the feedback they receive. This pilot is currently ongoing but has been well received by trainees and evaluators alike. 

Although this pilot is an exciting advance, it only fulfills our goals of facilitating timely trainee feedback. The pilot does not address our goals of creating an accessible trainee information platform where trainees are able to drive their own assessments and highlight their best work for the CCC.  It also only takes a small incremental step towards moving our assessment and feedback culture forward to be more open and meaningful.

Proposal Goals:

We plan to create an assessment system that addresses our CCC concerns of obtaining adequate assessment data for trainee promotion, trainee concerns of transparency, timeliness and quality of their assessments as well as faculty frustrations of “evaluation burn-out”.  Our proposal is to accomplish this by expanding EPAs as well as creating a user friendly trainee landing page to consolidate assessment data. 

Goal 1- To create a trainee “landing page” that enables residents to review their summative and activity-driven (EPA) assessment data with their advisors to facilitate understanding of their assessment data. 

Figure 1- Mock trainee landing page.

 

Goal 2- Give trainees more control over their assessment data that is presented to the CCC for entrustment.  Figure 2 demonstrates assessment modalities immediately available to the CCC.  Assessment data in red is available to the trainee and their advisor.  Through joint discussion they can release their best work for “entrustment” by the CCC.  For each EPA, trainees must release three “entrustable” evaluations done by three separate faculty members for evaluation by the CCC.

Figure 2- Types of data available to trainees, advisors and CCC

 

Goal #3- Improve timeliness, quality and specificity of assessment information for trainees while reducing evaluation burden for faculty by creating streamlined EPA assessment forms and handheld app to facilitate immediate completion.  The assessment editing will be driven by ongoing feedback from trainees and faculty from the current pilot project.

Goal #4- Utilize collected data from new information system to become more transparent about CCC deliberations with trainees.  With improved assessment data/information system the CCC will generate automatic entrustment emails for EPAs/procedures when trainees are signed off.  Similarly, we will be able to target earlier and more focused development efforts for residents who are not reaching their milestones appropriately.

Team Members:

Jeff Kohlwes MD, MPH.  School of Medicine.  Department of Internal Medicine.  Clinical Professor of Medicine. Director, PRIME Residency Program, Associate Program Director for Assessment and Feedback Internal Medicine Residency Program.

Patricia Cornett MD.  School of Medicine.  Department of Internal Medicine.  Clinical Professor of Medicine.  Associate Chair for Education, Department of Internal Medicine.

Vanessa Thompson MD.  School of Medicine.  Department of Internal Medicine.  Assistant Clinical Professor of Medicine. General Medicine Clinic Assistant Medical Director San Francisco General Hospital, Internal Medicine Residency Director of Academic Development

Sumant Ranji MD.  School of Medicine.  Department of Internal Medicine.  Associate Program Director for Quality and Safety.  Internal Medicine Residency Program.

Irina Kryzhanovskaya MD.  School of Medicine.  Department of Internal Medicine.  Senior Resident in Internal Medicine, Chief Resident-Elect.

Ray Chen MD.  School of Medicine.  Department of Internal Medicine.  Junior Resident in Internal Medicine

Comments

This idea is much needed on a GME level.  I could use it as a program director for a fellowship program at UCSF.

Thanks Eric!  Our goal is to make this available to all IM trainees- residents and fellows of all subspecialties (as well as key educational faculty).  Jeff

Empowering residents, and supporting them with a user-friendly platform, to solicit constructive feedback would be a major step forward for the residency program.  The literature around feedback suggests that when individuals actively seek feedback, as opposed to when they are given feedback without proper readiness to receive it, they are much more likely to to find that feedback helpful and to incorporate it into their practice.  Giving residents more ownership over soliciting feedback also has the potential to help us transform our culture into one in which learners and faculty alike are open to and constantly seeking opportunities for self-reflection and self-improvement.

Denise- thanks for your comment- I agree that if we can engage the trainees that we will improve not only the in the moment feedback- but over time- we can change the culture around feedback to where it becomes an ongoing give and take that facilitates learning amongst all our trainees!  jeff

This system would be a tremendous asset for the UC training programs. Despite numerous attempts at improvement and general acknowledgment of the great importance of feedback, current evaluations are often delayed, incomplete, and vague. Allowing learners to initiate the evaluation process will enable them to obtain feedback that is more relevant and to their needs. I also believe that the personal and specific nature of this feedback process will better engage faculty, yielding more timely completion and detailed comments. This is a win-win for trainees and educators!

Beth- thank you so much for your thoughtful comments- i could not agree more- we have to fix our ability to give real time feedback to our trainees.  They want it and it will improve the care that our patients get by enabling the trainees to grow.  Part of our plan will really focus on the second part of your comment- we need to design more faculty education to improve their skills at feedback so they can make valuable comments when the trainees ask.  Thanks again!  jeff

I love the idea (and am not impressed with eValue).  After a trail in DOM, please work to use this for other services (like ObGyn).  

Thanks for your support Leslee- actually that is hopefully the plan.  The goal is to create something that would be valuable for all GME programs as the challenges are so similar for all our residency (and fellowship) programs.  We hope to create an interactive function that will allow for residents to post about clinical encounters and then get direct feedback from faculty members (or other involved staff).  This could be especially valuable for procedural specialties as residents could post additions to their procedure logs and then get very rapid electronic feedback from their advisors!  Thanks for reading our proposal!

This will be a valuable trainee tool. What will be important is to make the user-interface easy, number of steps minimal, and quick access to the platform for both trainees and teachers.

Will teachers also be evaluated for their performance? Although that may not be part of ACGME, there is the value of feedback and promotions. How will this platform interface with E-value and if not, what is the incentive/mandate for this platform to be used? 

I am engaged with evaluating the training and trainee experience for proceduralist so will keep an eye on the development of your platform with much interest. Best of luck!

Ma- Thanks for your comments!  This will interface with Evalue with the goal of being a one step portal to all assessment modalities for the residents and fellows.  Initially the plan is to give each trainee and entry page and then expand it to the faculty who frequently assess them- our hope is that this will streamline the time and effort of assessment while making it much for specific and useful for the trainees.

Commenting is closed.

Empowering the EMR to help providers to choose and order tests wisely

Idea Status: 

Aim:

1)      To reduce redundant and unnecessary  specimen collection from patients with a new order entry strategy

Background:

                As a tertiary referral center, we see many patients who require multi-disciplinary care.  A majority of our patients receive care from multiple providers in different specialties, and as a result these patients often have redundant lab tests ordered.  This often results in submission of multiple specimens for overlapping tests in short periods of time.  The ease of ordering tests on our EMR has not improved our ability to streamline lab test ordering and specimen requirements for patients.  We seek to leverage the power of the EMR to improve coordination of care for patients. 

Proposal:

1)      Modify the EMR to have the order entry window appear parallel to a modified Results Display screen

2)      Flag future labs that have been ordered by other providers and allow easy modification for additional tests that can be consolidated

3)      Separate lab order entry panels into acute (1 time or short interval, recurrence) versus chronic (every 1-12 months, recurrence) to assist with the interface at the phlebotomy lab level

4)      Modify chronic order sets to include a range of acceptable time ranges for lab draws to occur (+/- 1 month for example), and allow the phlebotomist to adjust the lab draw dates to minimize blood draws)

Example:

This is the standard results window for a patient who had labs checked on 1/1/2015.

 

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

CHEM PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

Na

135

 

 

 

 

 

 

 

 

 

 

 

K

4

 

 

 

 

 

 

 

 

 

 

 

Cl

105

 

 

 

 

 

 

 

 

 

 

 

HCO3

24

 

 

 

 

 

 

 

 

 

 

 

BUN

10

 

 

 

 

 

 

 

 

 

 

 

Cr

1

 

 

 

 

 

 

 

 

 

 

 

Gluc

90

 

 

 

 

 

 

 

 

 

 

 

AG

6

 

 

 

 

 

 

 

 

 

 

 

eGFR

> 60

 

 

 

 

 

 

 

 

 

 

 

Ca

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON/ANEMIA PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

Ferritin

 

 

 

 

 

 

 

 

 

 

 

 

Iron

 

 

 

 

 

 

 

 

 

 

 

 

Transferrin

 

 

 

 

 

 

 

 

 

 

 

 

% Sat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

WBC

 

 

 

 

 

 

 

 

 

 

 

 

RBC

 

 

 

 

 

 

 

 

 

 

 

 

HGB

 

 

 

 

 

 

 

 

 

 

 

 

Hct

 

 

 

 

 

 

 

 

 

 

 

 

Platelet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THYROID

 

 

 

 

 

 

 

 

 

 

 

 

Parathormone

 

 

 

 

 

 

 

 

 

 

 

 

TSH

 

 

 

 

 

 

 

 

 

 

 

 

Free T4

 

 

 

 

 

 

 

 

 

 

 

 

Step 1:  Nephrologist sees patient on 01/2015 and wants to check 1) chem-7 every 3 months x 1 year and 2) Parathormone every 6 months x 1 year.  The following screen will display when future providers want to make additional lab order

 

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

1/1/2016

CHEM PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Na

135

 

 

***

 

 

***

 

 

***

 

 

***

K

4

 

 

***

 

 

***

 

 

***

 

 

***

Cl

105

 

 

***

 

 

***

 

 

***

 

 

***

HCO3

24

 

 

***

 

 

***

 

 

***

 

 

***

BUN

10

 

 

***

 

 

***

 

 

***

 

 

***

Cr

1

 

 

***

 

 

***

 

 

***

 

 

***

Gluc

90

 

 

***

 

 

***

 

 

***

 

 

***

AG

6

 

 

***

 

 

***

 

 

***

 

 

***

eGFR

> 60

 

 

***

 

 

***

 

 

***

 

 

***

Ca

9

 

 

***

 

 

***

 

 

***

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON/ANEMIA PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Ferritin

 

 

 

 

 

 

 

 

 

 

 

 

 

Iron

 

 

 

 

 

 

 

 

 

 

 

 

 

Transferrin

 

 

 

 

 

 

 

 

 

 

 

 

 

% Sat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

 

WBC

 

 

 

 

 

 

 

 

 

 

 

 

 

RBC

 

 

 

 

 

 

 

 

 

 

 

 

 

HGB

 

 

 

 

 

 

 

 

 

 

 

 

 

Hct

 

 

 

 

 

 

 

 

 

 

 

 

 

Platelet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THYROID

 

 

 

 

 

 

 

 

 

 

 

 

 

Parathormone

 

 

 

 

 

 

***

 

 

 

 

 

***

TSH

 

 

 

 

 

 

 

 

 

 

 

 

 

Free T4

 

 

 

 

 

 

 

 

 

 

 

 

 

Step 2: PCP sees patient on 03/01/2015.  He wants to check an acute CBC and thyroid test to work up excessive fatigue.  Since the patient already has a lab draw ordered for April, and the patient appears to be stable enough to have labs drawn in a month, the PCP orders a CBC and TSH/free T4 in April.  PCP also knows that a chemistry panel is already ordered and does not need to put in a duplicate order.  The phlebotomy system should recognize ALL orders placed for the April draw.

 

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

1/1/2016

CHEM PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Na

135

 

 

***

 

 

***

 

 

***

 

 

***

K

4

 

 

***

 

 

***

 

 

***

 

 

***

Cl

105

 

 

***

 

 

***

 

 

***

 

 

***

HCO3

24

 

 

***

 

 

***

 

 

***

 

 

***

BUN

10

 

 

***

 

 

***

 

 

***

 

 

***

Cr

1

 

 

***

 

 

***

 

 

***

 

 

***

Gluc

90

 

 

***

 

 

***

 

 

***

 

 

***

AG

6

 

 

***

 

 

***

 

 

***

 

 

***

eGFR

> 60

 

 

***

 

 

***

 

 

***

 

 

***

Ca

9

 

 

***

 

 

***

 

 

***

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON/ANEMIA PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Ferritin

 

 

 

 

 

 

 

 

 

 

 

 

 

Iron

 

 

 

 

 

 

 

 

 

 

 

 

 

Transferrin

 

 

 

 

 

 

 

 

 

 

 

 

 

% Sat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

 

WBC

 

 

 

***

 

 

 

 

 

 

 

 

 

RBC

 

 

 

***

 

 

 

 

 

 

 

 

 

HGB

 

 

 

***

 

 

 

 

 

 

 

 

 

Hct

 

 

 

***

 

 

 

 

 

 

 

 

 

Platelet

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THYROID

 

 

 

 

 

 

 

 

 

 

 

 

 

Parathormone

 

 

 

 

 

 

***

 

 

 

 

 

***

TSH

 

 

 

***

 

 

 

 

 

 

 

 

 

Free T4

 

 

 

***

 

 

 

 

 

 

 

 

 

Step 3: PCP has follow up appointment with the patient to review lab results.  Because the patient has microcytic anemia, PCP ordered chronic Fe study and CBC every 6 months (colonoscopy plus other work up for patient) to see the response of treatment.  PCP also wants to make sure bleeding is not brisk, so ordered an acute CBC in 1 month to ensure h/h stability.  In additional, because of the stability of the patient’s kidney function, PCP messaged Nephrologist via APEX and requested shifting chemistry lab draw. 

 

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

1/1/2016

CHEM PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Na

135

 

 

135

 

 

***

 

 

***

 

 

***

K

4

 

 

4

 

 

***

 

 

***

 

 

***

Cl

105

 

 

105

 

 

***

 

 

***

 

 

***

HCO3

24

 

 

24

 

 

***

 

 

***

 

 

***

BUN

10

 

 

10

 

 

***

 

 

***

 

 

***

Cr

1

 

 

1

 

 

***

 

 

***

 

 

***

Gluc

90

 

 

90

 

 

***

 

 

***

 

 

***

AG

6

 

 

6

 

 

***

 

 

***

 

 

***

eGFR

> 60

 

 

> 60

 

 

***

 

 

***

 

 

***

Ca

9

 

 

9

 

 

***

 

 

***

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON/ANEMIA PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Ferritin

 

 

 

 

***

 

 

 

 

 

***

 

 

Iron

 

 

 

 

***

 

 

 

 

 

***

 

 

Transferrin

 

 

 

 

***

 

 

 

 

 

***

 

 

% Sat

 

 

 

 

***

 

 

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

 

WBC

 

 

 

8

***

 

 

 

 

 

***

 

 

RBC

 

 

 

4.5

***

 

 

 

 

 

***

 

 

HGB

 

 

 

9

***

 

 

 

 

 

***

 

 

Hct

 

 

 

27

***

 

 

 

 

 

***

 

 

Platelet

 

 

 

200

***

 

 

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THYROID

 

 

 

 

 

 

 

 

 

 

 

 

 

Parathormone

 

 

 

 

 

 

***

 

 

 

 

 

***

TSH

 

 

 

2

 

 

 

 

 

 

 

 

 

Free T4

 

 

 

15

 

 

 

 

 

 

 

 

 

Step 4: Nephrologist receives the message from PCP.  Since the nephrologist is going to see the patient in 07/2015, he decided to keep the lab draw ordered for July but shifted future labs to go in line with CBC/Fe study.  In additional, the nephrologist also noticed the stability of the patient’s kidney function.  He decided to change chemistry to q6 months, too.  As a backup mechanism, the patient’s phlebotomist will also have the option to draw the patient’s 10/2015 and 11/2015 lab together.

 

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

1/1/2016

CHEM PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Na

135

 

 

135

 

 

***

 

 

 

***

 

 

K

4

 

 

4

 

 

***

 

 

 

***

 

 

Cl

105

 

 

105

 

 

***

 

 

 

***

 

 

HCO3

24

 

 

24

 

 

***

 

 

 

***

 

 

BUN

10

 

 

10

 

 

***

 

 

 

***

 

 

Cr

1

 

 

1

 

 

***

 

 

 

***

 

 

Gluc

90

 

 

90

 

 

***

 

 

 

***

 

 

AG

6

 

 

6

 

 

***

 

 

 

***

 

 

eGFR

> 60

 

 

> 60

 

 

***

 

 

 

***

 

 

Ca

9

 

 

9

 

 

***

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON/ANEMIA PROFILE

 

 

 

 

 

 

 

 

 

 

 

 

 

Ferritin

 

 

 

 

***

 

 

 

 

 

***

 

 

Iron

 

 

 

 

***

 

 

 

 

 

***

 

 

Transferrin

 

 

 

 

***

 

 

 

 

 

***

 

 

% Sat

 

 

 

 

***

 

 

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

 

WBC

 

 

 

8

***

 

 

 

 

 

***

 

 

RBC

 

 

 

4.5

***

 

 

 

 

 

***

 

 

HGB

 

 

 

9

***

 

 

 

 

 

***

 

 

Hct

 

 

 

27

***

 

 

 

 

 

***

 

 

Platelet

 

 

 

200

***

 

 

 

 

 

***

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THYROID

 

 

 

 

 

 

 

 

 

 

 

 

 

Parathormone

 

 

 

 

 

 

***

 

 

 

 

 

 

TSH

 

 

 

2

 

 

 

 

 

 

 

 

 

Free T4

 

 

 

15

 

 

 

 

 

 

 

 

 

 

Summary:

With the new ordering system demonstrated in the above case, we will be able to reduce the number of unnecessary and duplicate blood draws.  Providers will also be more able to communicate easily in order to perform tests together and reduce waste.  Lastly, this system will improve patient satisfaction and care by minimizing frustration for patients. 

Comments

This would be immensely helpful.  We know how nontrivial it is for our patients to go to the lab for phletobomy and should do everything we can to try to help them get what they need in an efficient manner.

I think that improving lab ordering would be a great thing.  Right now, I spend a lot of time checking "future labs" ("approximate dates") etc to avoid patient's labs orders being "used up" in advertently.

Commenting is closed.

Improving Apex interface to facilitate medical decisions

Idea Status: 

The Apex interface to find information on advance directives and POLST forms is very basic and deficient when searching for surrogate decision makers. In several instances the information is inaccurate or incomplete, leaving providers in the very difficult position of trying to implement the best interventions for each patient. This effort usually requires a substantial investment of time and resources in the attempt to clarify important directives with the patients or to search for decision makers. The aim of this proposal is to improve the accuracy of the current Apex interface and to create a new one to find surrogate decision makers. Such goals requires several steps: 1) Education of health care providers to conduct timely and adequate conversations with patients and families; 2) Streamlining the process of obtaining and entering advance directives and POLST forms in Apex; 3) Create in Apex an efficient search system for surrogate decision makers’ name and contact information. This will be the scholarly and QI project focus within the Social Work Fellowship in Palliative Care.  A social worker will be hired for advanced interdisciplinary training in Palliative Care and will assess and address the systemic issues related to documentation regarding surrogate decision makers and advance directives, enhancing the health care team’s ability to negotiate complex medical decision making with patients and families. He/she will closely work with different health care providers, including faculty, residents, fellows, nurses, unit clerks and IT analysts. 

Commenting is closed.

Electronic decision-making tool for the seriously ill

Idea Status: 

Patients with serious illness and their families face difficult decisions when diseases progress, or when complications and hospitalizations occur. Patients’ wishes closer to the end of their life are not often known, communicated through the health system continuum or honored. This proposal is aimed at creating an electronic decision making tool that will help patients and families with planning for treatments and procedures related to advanced illnesses. It will also help in identifying surrogate decision makers and will develop an interface with Apex. 

Comments

Giovanni - This is a great proposal and has some elements similar to Kara, Sirisha & my proposal. I agree that with our current technology patient's wishes are often not known and communicated through our existing technology. While our proposal aims to standardized documentation around advanced care planning through the EMR, I'm very interested in this idea of decision making tool for patients.

Can you tell me more?

And would you be willing to combine forces and potentially unify our proposals?

michelle mourad 

Great ideas, but rather than re-invent the wheel, you may want to look at our very own Rebecca Sudore's PREPARE website which is a patient-centered and driven decision making support tool. 

Thank you for the reference, Carla. I will look it up and see how it compares to my vision for the project.

Michelle, thank for your kind comments.

What I am referring to is a stepwise interactive tool that would provide patients with the evidence available made it easier to understand and tailored to the specific case, i.e. age, gender, primary and concurrent illnesses, etc. All to help patients and families in making decisions in advanced illnesses. For example decision for artificial nutrition and hydration like PEG placement or TPN, tracheostomy for long-term ventilation, etc.

Hope I satisfied your inquiry.   

Commenting is closed.

Employee time tracking

Idea Status: 

Time is money and timesheets are an essential procedure to appropriately calculate the number of hours employees have worked. Accurate and updated timesheets are legal documents and essential for protection in the event of potential litigation  over unpaid wages or missed meal breaks. If there is an issue with
payroll, a timesheet will be needed to verify the employee’s hours.  Timesheets are your “evidence” in the event of litigation and provide  all parties with a written record that can be used to fairly resolve  wage disputes.Timesheets are necessary for tracking hours, and calculating overtime when it is due. The timesheet indicates the time the employee begins work; the time they go to lunch; the time they  return from lunch and the time they leave work.  In many cases, especially in the labs there is a failure to complete timesheets, which result is inefficiently run labs and % efforts towards work on a grant that cannot be monitored.  It would be good to have either a card reader in the lab to track the work hours or an app for a smart phone that will track the hours and record the GPS liocation.

Commenting is closed.

Real-Time Feedback: Using the Electronic Health Record to Enhance Clinical Reasoning

Idea Status: 

Key team members:

Sirisha Narayana, MD, Alvin Rajkomar, MD, Victoria Valencia, MPH, James Harrison, PhD MPH, Sumant Ranji, MD, Division of Hospital Medicine, UCSF.

Gurpreet Dhaliwal, MD, Department of Medicine, SF Veterans Affairs Hospital.

Background:

Regular feedback on patients’ clinical course has long been recognized as a key factor in enhancing physician clinical reasoning and improving collaborative and team-based care (1, 2). The recent Institute of Medicine (IOM) report “Improving Diagnosis in Health Care” cited the lack of clinician feedback on diagnoses as a major contributor to the high prevalence of missed and delayed diagnoses (3). 

Provider surveys demonstrate the challenges in receiving feedback on medical decision-making. In the 2012-2013 ACGME survey, only 40% of UCSF Internal Medicine residents felt they were given data to show their personal clinical effectiveness.  A subsequent needs assessment from the Division of Hospital Medicine revealed that while many residents found value in learning what happened to their patients after discharge very few received this information consistently, either from their own reviews or from their ward attending physicians (4). Key barriers to longitudinal follow-up included time constraints, discontinuous training environments, and difficulty obtaining patient information. Attending physicians agreed that providing housestaff with this information was useful, but were limited by time constraints and the inability to extract the necessary information from the electronic health record in a methodical and efficient manner (4). Attending physician ability to retrieve this information to receive feedback on their own decision-making is likewise limited. 

We are currently employing an educational strategy to improve trainee feedback on clinical decision-making and to encourage self-directed learning: Interns on their patient safety rotation receive electronic lists of all the patients they cared for on inpatient general medicine ward rotations at Moffitt-Long hospital. Lists are generated using Structured Query Language (SQL) queries. They then review the EHR of their patients, guided by a reflection worksheet which provides a structure for the chart review. Lastly, they debrief with their peers at the end of the rotation on lessons they learned through this process. Based on preliminary analysis of this intervention, interns felt that post-discharge patient follow-up was extremely valuable to their professional development. They reported that reviewing patients’ clinical courses would change their future practices by advocating for earlier end-of-life counseling, improving discharge transitions, and adjusting their clinical decision-making while the patient was still hospitalized. 

Ultimately, however, they felt they would not be able to maintain this habit on their own without facilitation from either their training environment or the EHR. The IOM notes the importance of health information technology (IT) innovation in enhancing clinical reasoning in health care. Specifically, the electronic health record (EHR) could be used to automatically generate feedback to clinicians upstream thereby facilitating learning from outcomes of diagnostic decisions (3, 5).

Therefore, we propose developing an electronic method to track patients providers have seen in order to verify decision-making and promote feedback among providers. 

Proposed Intervention:

1. We would first conduct a needs assessment of physician, pharmacy, and nursing providers on their methods of patient follow-up (i.e. EHR review, patient phone call, word-of-mouth, etc).

2. We envision creating an active list within Apex which would auto-populate with the patients on whom a provider has written some form of documentation (i.e. progress note, H&P, discharge summary). This list would consist of the patient name, MRN, age, sex, date of admission, date of discharge, and discharge diagnoses (though these could be adjusted per provider preference). Separate columns would also be listed for number of readmissions (providers could refresh the list to provide the most up-to-date information) and new radiographic or lab results (with a direct link to the Apex inbox). Providers could use this list to conduct chart reviews on patients they have managed and learn from their clinical course. 

3. We would work with our nursing and pharmacy colleagues to determine the best way to depict similar information in their specific Apex view.

4. We would collaborate with IT specialists at the VA and SFGH to discuss the technological nuances that would facilitate a similar project in their EHRs.

This intervention would facilitate self-regulated feedback and enhance opportunities for clinical reasoning assessment.

References:

1. Schiff GD. “Minimizing Diagnostic Error: The Important of Follow-Up and Feedback,” Am J Medicine 2008.

2. Croskerry P. “The Feedback Sanction.” Acad Emerg Medicine, Nov 2000.

3. Balogh EP et al, “Improving Diagnosis in Health Care,” Committee on Diagnostic Error in Health Care; Institute of Medicine, National Academies of Sciences, Engineering and Medicine. September 2015.

4. Gottenborg E. and Ranji, S. “Post-Discharge (and Float) Clinical Feedback & Resident Education,” Division of Hospital Medicine Incubator Presentation, Dec 12, 2013.

5. G. Schiff and D. W. Bates. “Can electronic clinical documentation help prevent diagnostic errors?,” New England J Med. 362(12):1066–1069. 2010.

 

Comments

This is an obvious functionality of the EMR that I have wished existed many times, for everything from needing a case to present in report to wondering if my discharged patient's send-out test ever came back. It would also be a necessary first step to exploring how technology can mitigate the structural factors which limit continuity in training (such as short hospital stays and frequent rotation changes).

Hi Laura,

Thanks for your comment. Yes, the structural aspects of training are a definite issue. We are collaborating with folks at SFGH and the VA to determine the technological capabilities to provide such information. A work in progress!

Sirisha

I love this idea and think there are many ways to help make this happen on the Epic side. We should talk offline about a report in Epic to let providers see all patients they've written notes on in the last x days, and a way to impose a questionnaire on the same.

Thanks, Raman. Looking forward to chatting more about this!

Commenting is closed.

Discharge medication regimens made easier

Idea Status: 

 

Co-authors: Michelle Mourad and Kara Bischoff

Background:

Adverse drug events are important preventable causes of hospitalization in older adults, however compliance with a complex medication regimen after discharge home is known to be challenging for patients and particularly for the elderly. 

Objective: The aim of this proposal is to use technology to create easy to use color-coded charts with medication lists in large characters and with pills’ photographs. Technology would also be used to send the medication list to the patient’s PCP.

Methods: Interface APeX with a patient information medication information database to create a patient centered medication list. Potential information not currently included in discharge medication lists would be: Pill description, indication for use (antibiotic, blood thinner, control diabetes, etc.) as well as the creation of a tailored medication schedule of what to take in the morning, afternoon, evening and bedtime. 

Outcomes evaluated: Impact on patient care would be evaluated using the current post-discharge phone call program already in place. Patients are currently asked whether they have any questions about their discharge medications and if they have filled their new prescriptions. Secondary outcomes would be all-cause readmissions and readmissions for medication adverse events. 

Comments

Wonderful and much-needed. 

Fantastic, patient-centered idea.  It would be great if the formatted medication list you create could also be displayed and printed by inpatient providers, who could use the list to review the medications with patients.  Do you envision that the list could be "routed" to primary care physicians through the current workflow?

Alvin, 

Thank you for your comments. Yes, we can look into implementing your suggestions.

Commenting is closed.

A multidisciplinary mobile health superuser team to assist in adoption and implementation of mobile health apps in clinical care

Idea Status: 

The Problem:

There are over 165,000 mobile health (mhealth) applications available which can help patients with medication management, mental health, exercise, weight loss, symptom tracking, etc. However, these apps are being underutilized and physicians know very little about the full spectrum of apps available for patients. This is a tremendous underutilized resource that can empower patients to better manage their care, especially when they have complex medical conditions and treatment plans.

The Barriers:

1. Providers do not have time to identify the best mhealth aps for our patients

2. Even if mhealth apps are identified, it is difficult to implement patient and provider adoption of such technology

Proposed Solution:

Assembling a multidisciplinary team of mhealth app superusers to assist various clinic settings to identify technology options that will allow them to better take care of their patients. Such a team would include at least physicians, pharmacists, and patients who have protected time to identify and test mhealth apps/products and develop areas of expertise. For example, the team could work with a clinic that has identified medication management as a barrier for their patients. The team then tests medication assistance mhealth apps and could even evaluate SMS technologies for patients without smart phones and develop recommended tools to use. They can present this to the clinic and can work with the clinic on an implementation strategy that fits within the clinic work-flow to empower patients and providers to adopt the identified technology. Once this has been successful in a clinic environment, it could be distributed to other clinics facing the same challenge and the team can move on to a new area of need. This superuser team may also be able to work directly with mhealth companies identify unaddressed clinic needs that can be better addressed by mhealth in the future.

Comments

I love this idea as it seems that there is an explosion of clinical technology for clinical decision making but little quality control of them.  Similarly, it seems that our "screen procedure" for clinical apps should include a serious quality control made up of clinicians, field experts and computer information experts to ensure UCSF faculty use only the top quality materials for patient care.  When expanding on your project I would include who will be the stakeholders at the table and what process you will use to review the various apps.

Commenting is closed.

Leveraging the EMR to promote GOC documentation across transitions of care

Idea Status: 

Co Authors: Kara Bischoff & Sirisha Naranaya

Background:

Advanced care planning documentation is recognized as an important tool allowing patients to direct the type and intensity of medical care they receive. Systematic and educational innovations over the past decade have been effective at increasing the conversations around advanced care planning as well as the numbers of completed advanced care planning documents such as advanced directives (AD) and Physician Orders for Life Sustaining Treatments (POLSTs). 

Objective:

The goal of our proposal is to standardize advance care planning documentation and to create a centralized location in the chart for this documentation that is easily accessible across settings and to all clinicians caring for a patient. 

Description:

We reached out to a broad group of stakeholders across many disciplines and work areas including Primary Care, Oncology, Symptom Management, Home Based Primary Care, Housecalls, Population Health, Inpatient Palliative Care, and the Transitional Care and Heart Failure Program and identified the following needs:  

  1. Standardized Documentation: Templates and/or dot phrases to guide documentation of best practices for advance care planning
  2. A Central Location: One universally accessible location, such as a tab in Chart Review, where all inpatient and outpatient goals of care conversations and advance care planning documents can be quickly and easily found. Given the need for communication across transitions, a central location could also ensure that this documentation could be easily shared with partnering facilities across transitions in care.
  3. Clear Display of Key Information: A prominent location in the current outpatient workflow tohighlight important information, such as patients’ surrogate decision-makers andprevious code status orders, in a visually prominent place in ApeX across all care settings (e.g. devotinga portion of the “Snapshot” to Advanced Care Planning)
  4. Accessibility of Information Across Care Settings and Disciplines: Ensure that clinicians from all disciplines have the ability to document information about goals of care and advance care planning and have access to the same information.
  5. Discharge Summary: Improve documentation of goals of care in hospital discharge summaries

Based on these needs we propose the following interventions:

1. Standardized Documentation: Improve templates and/or dot phrases to guide documentation of goals of care: 

  • Create a dot phrase and/or note template for use in the Code Status and Advanced Directives note type
  • Create a dot phrase that can be used in the overview of Problem List problems “Goals of Care Counseling and Discussion” and “Advanced Care Planning”
  • Make these notes accessible to multiple disciplines, including social workers and nurse

2. Chart Review Tab: Create a central location where inpatient and outpatient goals of care conversations can be found

  • Change the tab in Chart Review from “AD/POLST/Legal” to “ACP/AD/POLST” or to “GOC Documentation”
  • Within this tab include:
  • All notes with the “Patient Care Conference” or “Code Status and Advanced Directives” note type
  • Problem List notes for the “GOC Counseling and Discussion” and “Advanced Care Planning” problems
  • Consider inclusion of “Significant Event” notes
  • Consider creating a new note type called “Goals of Care and Advance Care Planning”, which could be templated as above, to use for all such discussions
  • File scanned ADs and POLST documents in this tab

3. Snapshot: Create a section of the “Snapshot,” commonly used in the outpatient setting, where the presence of ADs, POLSTs and prior inpatient Code Status can be quickly seen (this is present in the banner bar in the inpatient setting). Make sure this is present for all clinical disciplines in all settings.

4. Discharge Summary: Improve the “Expressed Wishes” section of the current inpatient discharge summar

  • Make this documentation synergistic with documentation in the Problem List, ideally by pulling in the overview of the “GOC Counseling and Discussion or “Advanced Care Planning” Problem List notes.

5. Audit and Feedback: A report has already been created that allows us to audit inpatient documentation of advanced care planning. This will be used to feed data back to teams. 

Comments

I'm very impressed with the broad set of stakeholders you've assembled.  As a hospitalist, I appreciate that having documentation of goals of care in a consistent format that is easily accessible will improve patient care.  

Michelle, Kara and Sirisha,

The work you have done is very impressive for width and scope of the project. You have the foundation for a successful outcome that will benefit patients and providers.

 

Commenting is closed.

Protecting Patients from Unnecessary Emergency Room Visits and Hospitalizations: Harnessing Big Data to Directly Improve Clinical Care at UCSF

Idea Status: 

Authors: Alvin Rajkomar, MD and Sara Murray, MD

Background:  As many as 70% of emergency room visits may be preventable, with a proportion of these resulting in hospitalizations that may have also been avoided.  These preventable escalations of care, which we define as decompensations, cause personal and financial stress to patients and use of costly services by health systems which are increasingly focused on high-value care. There is a pressing need to be able to identify patients at greatest risk for imminent decompensation, with the intent on intervening prior to the need for emergency or hospital care.  Prior to use of our unified electronic health record (EHR), the data that contained the clinical status of patients was locked up in paper charts or disparate electronic databases that could not be analyzed without time-consuming manual chart review.   Our EHR now houses a wealth of clinical data in a single database that can be used for to help clinicians identify these high-risk patients, through high-throughput algorithms.  Much of the assessment of clinical status and risk of decompensation is contained within the clinical notes as unstructured free text (e.g. “The patient is calling to report worsening fever and chest pain.”).  Therefore, algorithms must not only able to quickly gather information about patients but also draw upon modern machine learning techniques to extract meaning from structured and unstructured data to assess patient status. Here we propose developing a novel algorithm that leverages the EHR to improve outcomes for our highest risk patients across the medical center.

Proposal:  We propose building a machine-learning model that employs deep learning (e.g. deep neural networks), including processing of free text from clinical notes/encounters, to predict a given patient’s risk of emergency room visit or hospitalization within the next 7 days. To do this, we will first assemble a data repository of all patients receiving care at UCSF by extracting the subset of the EHR that includes clinically relevant structured data (demographics, laboratory data, encounters, problem lists, etc.) as well as all of the clinical notes for each individual patient.   Using this data repository, we will develop an algorithm that accounts for the patterns and content of an individual’s interactions with the healthcare system.  We plan to deploy this algorithm on a bi-weekly basis to identify UCSF patients at greatest risk for decompensation and feed that information back to key stake-holders (including primary care clinics, the accountable care organization, and ideally a call system to check-in on these patients).

Feasibility: This project is feasible for our team, as it builds upon and synthesizes prior work we have done in validating data extraction algorithms from the EHR, streamlining storage and processing of large amounts of EHR data, and building machine-learning algorithms to be used in predictive modeling. Both primary investigators are Clarity certified and have direct access to generate this data repository.  Dr. Murray has already built a similar data repository containing structured data and unstructured free text for use with machine learning algorithms in lupus patients.  Dr. Rajkomar has already built and is using a computational server that pulls and analyzes EHR data in real-time and has created deep learning algorithms on high-throughput computational clusters.  Both primary investigators have collaborated with Epic build-team members in prior projects and understand how to push data from an algorithm back into the EHR.

 

This would be a highly novel application of health IT in which we synthesize big data - nearly the entirety of the EHR - and use the machine learning to directly improve clinical care. We anticipate that this project will not only help us reduce emergency room visits and hospitalizations at UCSF, but also serve as a model that fundamentally changes how we use EHR data to affect patient care.  The fundamental premise of real-time processing of clinical data at scale has multiple applications for the Department of Medicine and UCSF Health, as the same pipeline could be used to predict an infinite number of outcomes that are important to our health system and the patients we serve.  

Comments

This is a very exciting and innovative project that could have important implications for quality of care, patient satisfaction, and education. If possible, it would be very interesting to incorporate patient MyChart messages into the algorithm (although this may raise consent issues.) Another potential application would be predicting patients at high risk of rehospitalization after discharge, as our current tools for assessing readmission risk are imperfect.

Hi Sumant,

Thank you for your kind comments.  We, of course, will seek IRB/CHR approval, but we are planning on using the rich information in MyChart messages to help with the prediction.  For example, a patient with repeated MyChart messages indicating that they are having trouble obtaining a high-risk medication may have an elevated risk of seeking resolution in the emergency room rather than with their outpatient team.  Can we train an algorithm to identify this high-risk situation and flag it for further review by the health system?  Other industries do this quite well; for example, credit card companies will temporarily invalidate credit cards if they suspect fraud with very similar mechanisms: an algorithm flags purchases that are likely fraud and then pushes the account to a human who investigates further.

Predicting high risk of rehospitalization is a natural extension of our project, as I suspect we'll find that patients who have been recently hospitalized are at elevated risk of seeking a hospital care again.  With the granularity of data we are looking at, I also suspect that we'll find different factors that predict re-admission from patients discharged from the surgical services compared to those discharged from the general medicine service.  

Best,

Alvin

This is an exciting and innovative project that will harness data from the EMR to potentially identify patients at high risk of readmission. This has important implications for our health system, patients and families, physicians and trainees. If successful this model could be used for a number of different clinical and patient situations. I would like the authors to carefully consider how the data from their algorithm will be fed back to various stakeholders (our organization, clinical teams, individual providers, patients). How will the data be presented, delivered and how will you ensure it is actionable? 

Hi James,

Thanks for your excellent comments.  We agree that feedback of the results of our algorithms into the health system is a critical point.  We need to balance the need to give timely and important alerts to care teams with the need to avoid alert fatigue.  One of our first tasks will be to ensure that our predictions are timely and actionable, which we can evaluate ourselves as physicians as well as with important stakeholders like primary care physicians and the accountable care organization. Because care teams have many competing priorities, we need to tailor the types of feedback depending on urgency and capacity to intervene.

We are currently running a randomized clinical trial of delivering data to UCSF clinicians using electronic dashboards.  This data is actually from the Clarity (UCSF EHR) database and runs on servers within UCSF, so we have expertise with the dashboard process and developement cycle.  Our team also has significant experience working with the Epic build teams and can work with physicians to find managable ways to intervene in Apex (e.g. we have the practical know-how to create Apex alerts and inbox messages).  

We are fortunate that we already have the capacity in our team to make data available and presentable to clinicial teams, although before we commit to deciding exactly how we will intervene, we will need to have more discussion with stakeholders to make sure that we come up with a solution that streamlines care rather than just adds work on clinicians' plates.  It's possible that we need health professionals from outside a patient's primary care team to do the initial outreach to high-risk patients.  We would love to hear from others if they have suggestions.

Best,

Alvin

I really like this idea - clinically focused, a direct patient outcome, cost-saving, and utilizing technology to enhance human decision making.

Thanks, Henry!

Alvin - like others, I think this is an exciting idea. I humbly suggest that as you move this forward, you will need primary care partners to help you make decisions from beginning to end, including algorithm creation and testing, and implementation work-flow development and testing.

Hi Leah,

Thanks, and I totally agree.  If we are selected to move forward to round 2, we will definitely seek out primary care partners to be part of the final project proposal.  Please let us know if you know anyone who might be interested!  

Best,

Alvin

Sara, Alvin--I, too, love this idea, and agree with the comments Leah, James, and Sumant have made about thinking carefully about how you get data back to the stakeholders, especially including the PCP and the patient. As you may know, MyChart and Inbasket both have APIs that you can leverage when it comes time to deliver the actionable data to the key stakeholders. Other deeper integrations with the EHR may also be possible--we should talk more about these as you ramp up this exciting project!

Awesome proposal. I think chipping away at the high number of preventable emergency room visits is an important cause. I especially like that you are thinking not only about reducing visits to the ED, but how to use data to improve patient care. I agree that MyChart messages would be a great additional set of data for this algorithm.

Good luck!

Thanks, Rhiannon!

Thanks Rhiannon!  One of the really exciting things about processing the free text in mychart messages is that - since in many cases they aren't read immediately (although we know many providers do!) - our algorithm will have the potential to incorporate/process information that is transiently unknown even to the providers.  Initially we will run the algorithm on a schedule as detailed above, but once it is succesful we could imagine scaling it up to a near-daily process that identifies very high-risk patient situations and can feed that back to providers very quickly.

Great idea - really pushing the edge of what is known about preventing adverse events. Another interesting input would be the post discharge phone calls. We are currently analyzing these calls to determine the association between answering the calls, participating in the phone survey and selecting the option to talk to a nurse or someone from patient relations and both readmissions and patient satisfaction. There are future plans to integrate this data into APeX.

Looking forward to seeing what you find! 

Hi Michelle,

Yes - that's a fantastic idea.  Occasionally I have seen notes from the amazing 14M/L nurses who have documented information about these conversations (which we will be able to extract directly), but we will definitely think about extracting some of that structured data, as well.  If Cypher has an API (application programming interface) we could think about pulling the data from their system directly as needed, as we have done that for some of our analysis before.

Thanks for your support,

Alvin

I also love this idea, particularly if we extend the project to readmissions which is a natural next step.  Let me know if I can help with the cipher APeX integration!

Commenting is closed.

UCSF Apex Hackathon

Primary Author: Priyanka Agarwal
Idea Status: 

It is a common perception on campus that "Epic is closed and doesn't want to talk to outside systems."

While there is a kernel of truth in this observation, Epic actually has several standard, robust Web services--and additional customized ones written by our APEX developers--through its interconnect API. After undergoing appropriate security review, YOUR application idea can connect to UCSF's electronic health record in a way that lets it read the patient roster, the treatment and care teams, and even vital signs and some lab values. This data can be used for everything from syncing lists to creating a "second skin" over Epic for specific clinical leads like a nephrology clinic or endoscopy suite.

In that spirit, we are proposing an APEX HACKATHON. Bring your developer friends, come prepared to write code, or just come with a great idea about what you could do with access to certain parts of the EHR IN REAL TIME. Want to see a beautiful graph of medication burden for your clinic panel? Want to track and plot your patients' immunosuppressant levels X days out from transplant, and build in logic for when a level is or isn't therapeutic? No idea is too hare-brained. Spend 24 hours writing code and building an application that connects to one of the practice, non-PHI environments in teams, getting practice for when/if you want to do the real thing.

At the end of the Hackathon, participants will submit their developed ideas for demonstration and the best idea will win a cash prize and the opportunity to develop the idea further in the UCSF environment. Any code developed at the Hackathon is owned by the developers.

The Hackathon will be great for advancing the digital health space for DOM, not least by building partnerships with developers and within our own institution, and for giving our incredibly smart community a taste of what can be achieved with what Epic already allows.

If the DOM funds this proposal as part of the IT challenge, we'd use the money to plan and put on the event, including giving out prizes.

Thanks for liking and commenting on our proposal!

Raman Khanna, MD

Aaron Neinstein, MD

Priyanka Agarwal, MD

Comments

This is a great idea and I'm fully supportive.  I suspect many participants will be from outside UCSF - how will the hackathon prevent unauthorized access to protected health information?  

Thanks Alvin for this comment! It's a great question. For sure no developer will touch the actual Apex environment, but will develop instead against a "play" environment that has neither any real patients, nor is it on a "path to production" (meaning the code has no chance of moving automatically into the real patient environment). I've modified the proposal to reflect this subtlety which wasn't clear before.

I've always loved this idea to let developers access the Interconnect API's, but there are these limitations that will affect the scope of a potential hackathon:

  • You need to be an UCSF employee or sanctioned contractor/consultant to see the API documentation.  Epic discourages (prevents?) you from using the API's unless you've been to their Interconnect API training in beautiful Verona, WI.
  • There is no built-in authentication or authorization, though there are a couple of workarounds using authentication proxies.  Without using a proxy, you're constrained to apps that work only within the UCSF network
  • You'll need a sandbox Epic environment with realistic looking, but fake data, most likely separate from what exists today so as to not interfere with other development work occuring.  There are over 200 API's, i.e. a substantial amount of data will need to be created for full coverage of functionality.  For developers to create their own test data, they would need M (Epic programming language) skills and knowledge of how the data is stored in Cache (Epic's hierarchical [non-relational] database), both of which require another trip to Verona, WI in order to acquire.
  • Any apps developed in the hackathon aren't necessarily portable to other institutions.  It depends on the API version availability in the other institutions' installed version of Epic.

These aren't insurmountable, but they're not trivial, either.  You'd have to organize the hackathon to compensate for these obstructions.

 

Commenting is closed.

Innovative, patient-centered, interactive website to facilitate advance care planning

Primary Author: Rebecca Sudore
Idea Status: 

Problem Statement: Millions of older adults and their families will face complex medical decisions over the course of advanced illness, yet most are unprepared. Lack of preparation can lead to uninformed choices, receipt of care inconsistent with personal goals, and lack of empowerment during clinical encounters, especially for individuals with limited health literacy. Conventional preparation, called advance care planning (ACP), has typically focused on having patients pre-specify preferences for life prolonging procedures, such as mechanical ventilation, and to document these choices in an advance directive (AD). Yet, ADs are hard to understand and are often not completed, especially by minorities. And, even when ADs are completed, they often fail to affect the care received at the end-of-life, decrease the stress of decision making, or result in what most experts agree is the most important component of ACP – ongoing conversations between patients, their loved ones (i.e., surrogates decision makers), and clinicians. To overcome these limitations and unmet needs, we developed a new paradigm of ACP that focuses instead on preparing diverse, older adults and their loved ones to communicate their evolving wishes over time and to make real-time, complex medical decisions over the course of chronic and advanced illness.

 Innovation: To operationalize this NEW ACP paradigm, we developed the PREPARE website. PREPARE (prepareforyourcare.org) was created in partnership with English and Spanish-speaking older patients, their families and surrogate decision makers, and community stakeholders through extensive focus groups and cognitive interviews. PREPARE is based on behavioral change theoryand, unlike other ACP programs, includes preparation for decision making and videos on how to communicate with surrogates and clinicians (e.g., how to ask someone to be a surrogate and how to communicate one’s evolving goals).PREPARE is interactive and tailored to peoples’ preferences. Rather than just focus on CPR or mechanical ventilation, PREPARE preferences include detailed information about who, when, and how a surrogate should make decisions; what gives life meaning; desired involvement in medical decisions; and communication preferences. These preferences, and an action plan to complete ACP, are provided in a printed “Summary of My Wishes” for the patient, family, and clinician. PREPARE is written at a 5th grade reading level, can be completed outside of a clinic visit, and has been shown in research studies to be easy-to-use by diverse, older adults. It is has been translated into Spanish and is currently being translated into Mandarin and Cantonese.

Potential Impact: Preliminary studies show that PREPARE helps people engage in ACP without the use of a facilitator; therefore, it can be completed outside of the clinical environment. In addition, because the website prepares patients and their loved ones for medical decisions and discussions, it may save clinicians’ time as well as help facilitate new (January 2016) CMS reimbursement for ACP. PREPARE has also shown promise to improve patient and family satisfaction with clinician communication – an emerging quality metric important to UCSF. And finally, PREPARE may also decrease health disparities in ACP by providing easy-to-understand and accessible ACP information to a diverse audience of English and Spanish-speaking adults.

Current Impact: PREPARE was launched for free to the public and since then has been viewed by over 60,000 unique users with over a million page hits in over 115 countries. UCSF also has several licensing agreements with other academic institutions for research and clinical entities for use in ACP programs. Dr. Sudore has also been awarded a VA IIR grant, an NIA R01, and a PCORI grant to test the efficacy of PREPARE in 3 large randomized trials in diverse, disenfranchised English and Spanish speaking populations.

Future goals: Additional funding for 2 main efforts would greatly enhance the functionality and the reach of the PREPARE website for UCSF patients, as well as patients in Californian and nationally. First, Dr. Sudore designed and tested an easy-to-read advance directive (http://www.iha4health.org/our-services/advance-directive). Additional funds would allow the integration of this directive into PREPARE. This directive combined with the PREPARE values summary will further ensure that the patients’ wishes are honored and make it easier to meet CMS reimbursement standards for ACP. Second, we have started translating the PREPARE text into Chinese and are seeking funding to update the audio and videos into Mandarin and Cantonese.

Comments

This is such an innovative tool to help align treatments with patients goals and values.  Integrating an easy-to-read Advance Directive into this tool will be fantastic and help a lot of people, especially with translations in different languages.

This is an incredibly important initiative that will increase the likelihood of patients receiving the care they want. 

As a primary care geriatician, I believe that this resource will be an easy and effective tool to use in the clinc setting to enable patients and families to have the important conversations necessary to establish accurate goals of care.  It will facilitate true patient centered and cost effective care.

Commenting is closed.

Bed Rec: A Simple Order Reconciliation Tool for Better Patient Sleep

Idea Status: 

The problem: Hospitalized patients get fewer than five hours of sleep a night.[1]

Poor sleep leads to increased rates of delirium, falls and hypertension, and to lower patient satisfaction scores and longer hospital stays. [2], [3], [4] Nighttime disruptions – including vital signs, lab draws and medication administration – are a major contributor to poor sleep. These clinical activities can often be shifted to waking hours without compromising patient care.

However, Apex is not currently able to show physicians the orders that will occur at night, or to give physicians the option to easily change them to waking hours.

That’s where Bed Rec comes in.

How it works: Prior to signing out for the day, a provider opens the Bed Rec tab. Under this tab, Apex will list the active orders that will take place during “sleeping hours” from 10pm to 6am.  Providers will then have the option, if clinically appropriate, to cancel these orders or shift them to waking hours.

Examples of Bed Rec in use:

Vital signs

  • Bed Rec shows vitals are scheduled for Q4 hours, taking place at 8pm, 12am and 4am.
  • This patient’s vitals have been stable and suspicion for clinical deterioration is low, so the provider can change vitals to 10pm and 6am

Medications (switch to PRN)

  • Bed Rec shows Zofran is a q6 hour “standing” order and is scheduled at 8pm, 2am, 8am
  • The provider can change the 2am dose to “PRN” while keeping the daytime doses “standing"

Medications (switch to TID)

  • Bed Rec shows amoxicillin is written for Q8 hours and the patient will be woken to receive a dose at 4am
  • This medication can safely be given three times a day during waking hours rather than strictly every 8 hours, so the provider can change it to TID and schedule a 6am dose.

Labs

  • Bed Rec shows that the patient is scheduled for a 4am BMP and CBC.
  • The provider can change the labs to 6am.

Obstacles and Concerns:

1. Patient Safety

If we monitor patients less closely at night, will this compromise our ability to recognize clinical deterioration? To address this concern, the Bed Rec tool will have validated decision support built in. The Modified Early Warning Score (MEWS) uses recent vital signs to identify patients who are at high risk for an adverse event or clinical deterioration.[5] Patients with MEWS scores of one or less have adverse event rates of just 5.0 per 1000 patient-days, compared to patients with MEWS of seven or greater, who have adverse event rates of 157.3 per 1000 patient days.[6]

On the page where nighttime vitals are listed, the MEWS score will also be listed in green, yellow or red, and labeled low-, medium- or high-risk for clinical deterioration. Providers will be advised not to forego vitals for the ~50% of patients with a MEWS of greater than one.

 

2. Will busy residents and attendings really take the time to use this tool?

One of the most common complaints we hear when rounding on patients is that they slept terribly. If the interface is user-friendly and intelligently built to allow for changes with the fewest number of clicks, residents will view this as a “high-yield” use of time. They will be able to give patients eight hours of uninterrupted sleep (a treasured commodity in the medical field) in a minute or less.

Proposed by Timothy Judson, MD, MPH, and Michelle Mourad, MD


[1] Beveridge C, Knutson K, Spampinato L, et al. Daytime Physical Activity and Sleep in Hospitalized Older Adults: Association with Demographic Characteristics and Disease Severity. J Am Geriatr Soc. 2015;63(7):1391-400.

[2] Figueroa-ramos MI, Arroyo-novoa CM, Lee KA, Padilla G, Puntillo KA. Sleep and delirium in ICU patients: a review of mechanisms and manifestations. Intensive Care Med. 2009;35(5):781-95.

[3] Gangwisch JE, Heymsfield SB, Boden-albala B, et al. Short sleep duration as a risk factor for hypertension: analyses of the first National Health and Nutrition Examination Survey. Hypertension. 2006;47(5):833-9.

[4] Young JS, Bourgeois JA, Hilty DM, Hardin KA. Sleep in hospitalized medical patients, part 1: factors affecting sleep. J Hosp Med. 2008;3(6):473-82.

[5] Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. QJM. 2001;94(10):521-6.

[6] Yoder JC, Yuen TC, Churpek MM, Arora VM, Edelson DP. A prospective study of nighttime vital sign monitoring frequency and risk of clinical deterioration. JAMA Intern Med. 2013;173(16):1554-5.

Comments

Tim, this is a great idea. We piloted something similar at the VA. We used the MEWS and patients with a score of 1 or 0 we wrote an order for no overnight vitals. The number of patients was small but we did not have any adverse events. Now, this is an informal practice. The data collection and implementation were time-consuming.

This could be greatly improved with technology as you propose. Perhaps for patients with a low MEWS vitals are automatically discontinued overnight and it is an 'opt in' practice. I would love to see this expanded - we just did not have the resources. Send me an email if you'd like to know more of what we experienced.

Tim, Congrats on an innovative and thoughtful proposal. Anyone who has spent a night in the hospital knows that sleep is a precious commodity, and your unique approach takes a systems approach to sleep preservation. I look forward to helping you make this a reality funding or not! 

Tim this is awesome. Im for it!

Great idea - I think the culture of our residency is such that we actively think about these issues but it has been extremely challenging for me to manually navigate Apex to ensure our patients sleep better and get disturbed less. Bed rec will make this a lot easier!

This is a great idea and I think that it will be truly appreciated by patients. One additional idea for promoting sleep is to add melatonin PRN to the bed rec (or automatically for all patients). As a crosscover I received many "patient requesting something to help them sleep" pages and would always start with melatonin. We can empower RNs treat hospital-acquired insomnia independently with melatonin since there are no significant adverse effects at the doses we use in the hospital.

PRN low dose melatonin would be a great addition for many patients. This sounds like something that could easily be a "check-box" item on the Bed Rec tool. Thanks for the idea Scott!

Great idea Tim! Really like the idea of being able to change the PM orders, but still be able to leave the daytime orders as is!

Commenting is closed.

Let the patient know estimated time to seeing physician APP

Idea Status: 

As a recent patient in one of our clinics, I arrived 30 minutes early for a blood draw after being told that was possible, since I had a scheduled a 30 min. meeting with a colleague.  I waited 50 minutes for a late blood draw.  After the blood draw, I then waited another hour  for the appointment.   Keeping the patient informed on approximate time ( like waiting for a delayed airline flight)  The airlines have such an app, why not UCSF?   Scheduled and estimated times would be shown on the patients smartphone app.  I waited from 1PM to 4:30 for what was a 1 hour appointment.  I could have gotten my Starbucks, kept my short appointment if I had this information.  

This app will help clinicians know when blood was taken on their patient and help them schedule their time.  The app would help keep patients happy and would save staff time from being interrupted by people asking when they would be seen.  For administrators, this app would show bottlenecks in the system that need fixing and could increase productivity of the clinic.

This would benefit all, should be fairly simple to create for our clinics.

Commenting is closed.

Lose the paper surveys

Idea Status: 

Lose the paper surveys. They waste everyone’s time from the receptionest to the patient to the records clerk to the physician. The Questionairre could be accessed from the home computer through the 'UCSF 'my chart application' and it would become instantly paperless and quick reading for the clinician when preparing for the patient visit.

This application could save time and instantly become part of the patient record.  This would save staff time in checking in patients, save patient time and would get rid of 1950 style paper records.

For those that do not use computers, offer kiosks with touch screens. 

Comments

Hi Dr. Hughes-Fulford,

There is current functionality in MyChart that enables questionnaires to be sent to patients!  You may have already explored this, but if not feel free to contact us and we can point you in the right direction.

Best,

Sara, Raman, and the medical informatics team

Commenting is closed.

Develop the Infrastructure for Any Investigator to Build a Web-Based Cohort Study

Idea Status: 

Cohort studies are a critical component of clinical and translational research. They provide data on the natural history of disease, biobank specimens for translational studies and often provide a framework from which one can recruit for clinical trials. Traditional cohort studies also have many drawbacks. Data collection is often still performed on paper and management is usually centralized at a data-coordinating center with limited ability for interested investigators to obtain transparent, real-time information on data and specimens available for study. Furthermore, these studies only collect data at scheduled study visits often separated by long periods of time and require patients to travel to the institution for data collection. Frustration with the lack of transparency, limited data collection as well as the glacial pace of clinical research provided inspiration for the development of mobile and web-based platforms for cohort studies. These platforms revolutionized data collection, allowing data to be obtained at virtual study visits as well as throughout the intervening period via mobile and web-based applications and sensors. They also allowed investigators to share data with patients increasing patient involvement. At present, this form of observational cohort is limited in its ability to biobank specimens. In addition, study retention and engagement are important challenges, particularly when patients do not have a face-to-face meeting with a clinician and study coordinator. 

I propose that the DOM provide infrastructure to create a hybrid model that would allow investigators to enroll patients from clinical sites into mobile or web-based cohort studies with biobank integration and a HIPAA compliant cloud storage solution.  The patients will then remain tethered to the study through mobile and web-based applications, which can significantly decrease the frequency of brick and mortar study visits and increase the frequency of data collection. The DOM would provide the following:

  1. Template for creation of a web-based tool for data collection
  2. Cloud based HIPAA compliant data storage solution
  3. Biobank interface
  4. Relationships with common APIs including transactional email platform, customer support software, etc.
  5. A location where mobile tools and sensors can be shared across disciplines

The goal of developing this infrastructure is to decrease the activation energy needed for investigators to create their own modern cohorts.

Commenting is closed.

Defining and connecting the dots: a novel low-code healthcare process manager

Idea Status: 

Key Team Members:  Cheong S. Ang, MS, MBA, Grace Chen, MS, Lisa Hsiao, MArch, and George Su, MD

Problem Statement: Healthcare is complex, and some key intricacies come from linkages between stakeholders, agents, and dependencies. These are further complicated by care adjustments, iteration, inconstant human behavior, and inherent health and safety implications. Healthcare delivery can be distilled, however, as in other industry sectors, down to relatively simple processes. Despite a widespread strategic focus on process in healthcare, process management in healthcare remains profoundly underdeveloped. Dominant existing tools, such as the electronic medical record (EMR), are designed to house static data, and less to manage, map, or codify active processes. Thus, the healthcare system is relegated to managing healthcare processes with ad hoc workaround solutions, in addition to EMRs, such as spreadsheets, email prompts, calendars, and project management platforms—not to mention high-effort solutions like checklists and registries.

Innovation:  We’ve developed a novel, low-code application that organizes and contextualizes healthcare processes into a care pathway map, so that all users – from the healthcare team to the patient – are aware of and accountable to the healthcare plan. This involves the distillation of main healthcare processes into a kit-of-parts of “Actions and Nodes” which organizes workflows, tasks, manipulated objects (e.g. documents and records), roles, and agents into a timeline of tasks, dependencies, and results. This inherently flexible application transforms the volume of data for an individual into a coherent patient story. It also creates a powerful tool that can be used to optimize workflows, clinical care, and patient engagement.       

Solution description:

A.  Care pathway map

  • A user-centered synthesis of process elements (e.g. “patient journey” or “administrator workflow”) maps Actions and Nodes into an IoT (“Internet of Things”) mesh network.
  • The execution of Actions can be manually or automatically documented.
  • Nodes are junction points that, depending upon clinical inputs (tests, labs, diagnostic studies, provider decisions), can trigger new actions in a patient’s overall care pathway.
  • Users, including “agents”, “team members”, “stakeholders”, “patient” etc. are assigned “roles” and relevant preferences.
  • Add-on functions, such as task listing, reminders, prompts, document management (faxing, e-signatures), and communication modalities (email, SMS), are configured to function within Actions and Nodes.
  • Customized task lists are sortable by due date, priority, responsible party, care path destination, care path status, activity level, risk category, patient identifiers and characteristics.

 B. Analytics package for Process Management

  • Identifies key metrics to measure achievement of goals, outcomes, and efficiencies
  • Constructs “intelligent care pathways” through business intelligence and process goal targets
  • Compares different pathways, clinics, and systems through benchmarking
  • Provides a simple way to generate special reports, e.g. Chronic Care Management (CCM) effort reporting

Potential Impact:  A legitimate process management tool for healthcare has promise to dramatically improve provision of patient care. Efficiencies are realized by automating manual tasks and eliminating redundancies. Accountability and safety are enhanced by enforcing priority levels, driving task completion, maintaining pathway momentum, closing follow-up gaps, and raising attention to vulnerabilities. Patient involvement is encouraged and patient satisfaction is increased through new engagement opportunities at Actions and Nodes. Healthcare systems will have the agility to adapt to changing conditions, leverage newly-transparent processes to improve operational decision-making, and utilize new tools to intelligently manage process-related costs.   

Current solution status:  An IoT mesh network platform prototype and a minimally viable product (MVP) have been built (see attachment for sample screenshots). We seek funds to continue software development and to support evaluation of a pilot project based at San Francisco General Hospital. We also seek UCSF product development expertise and counsel.

 

Supporting Documents: 

Commenting is closed.

Recorded patient instructions: bridging the gap between written and discussed plans

Idea Status: 

Team:  Sara Murray, Michelle Mourad, Jinoos Yazdany, Maria Otto

Background 

Multiple studies have shown that recording discharge instructions for patients improves their understanding of their disease and improves outcomes such as hospital readmission.  Likewise, in clinic appointments, patients forget as much as 80% of what their doctor tells them.  Many physicians spend a great deal more time explaining things to patients in both the inpatient / outpatient settings, but this is often not captured for patients in a permanent way.  Voice recording offers a unique opportunity to improve patient care, satisfaction, outcomes such as readmission and understanding of complicated directions from outpatient visits.  While it has been tested and implemented at other institutions in the inpatient setting with favorable results, it is not yet standard of care for hospital discharges. In addition, since most care is administered in the ambulatory setting for chronic disease, it has potential to be utilized in that setting with equal benefit to patients and providers.

Proposal 

We propose implementation of technology that enables voice recordings of patient instructions and complicated conversations in both the inpatient and ambulatory settings at UCSF.  We will partner with a company (such as building upon our existing institutional relationship with Cipher using their Echo platform) to trial implementation of technology that has already been developed. This platform will enable patients to have an application on their phone (loaded with the assistance of patient-care assistants or medical assistants), and providers would be able to record their discharge or final clinic conversations for later reference.  Recording conversations would be optional and editable for providers.

These conversations could be integrated into Epic and MyChart.  Long-term, we would like to be able to present the same information in multiple ways to patients, including not only the audio instructions but also speech-to-text translation that they could read within the interface.   This could also potentially replace current patient instructions in the medical record if the provider wishes (to avoid increasing provider work-load).

We propose initially implementing this technology as a RCT that involves several ambulatory clinics and inpatient medicine teams. Providers would be randomized over a 3-6 month period, with half utilizing this method and half using the current standard-of-care (typed patient instructions included in the AVS).  We would then collect feedback and measure qualitative outcomes (patient and provider satisfaction) to be used for iterative improvement of the technology.  We would also measure longitudinal outcomes (readmissions, adherence to treatment and appropriate monitoring) to assess the long-term impact in our patient populations.

Commenting is closed.

There’s an App for That: Developing and Building a UCSF Health Smartphone App to Enhance Communication with Patients and Improve the Patient Experience

Idea Status: 

Authors: Catherine Lau, James Harrison, Sarah Imershein

Background:

UCSF Health is committed to being the best provider of health care services and has dedicated many resources to improving the patient and family experience. Although the focus of improvement efforts has been communication coaching for providers and improving the provider experience, UCSF Health and other healthcare organizations have also begun leveraging information technology (e.g. MyChart, OpenNotes) to further empower patients and families with the goal of improving overall patient experience and health outcomes.  

The idea of further leveraging information technology to improve the patient and family experience also comes from patients and families themselves. A recent patient and family focus group strongly recommended that UCSF build a smart phone application that would allow them to be better informed about their care while being hospitalized. A separate Patient and Family Advisory Council at UCLA also made this recommendation and took this a step further by working with their local IT experts in developing an easy-to-use, intuitive, and informative smart phone application that is currently available for download from the iTunes store. The UCLA application has received rave reviews by patients, families, and healthcare providers.

Proposal:

We propose that the Department of Medicine develop and build a UCSF Health smart phone application with the aim of enhancing existing provider communication with patients and families while also better supporting patients and families when they receive care at UCSF Health. The initial app development will include adult inpatient medicine and any ambulatory practices or other departments/divisions that wish to participate. As the needs and wishes of inpatient and outpatient providers and patients will be different, separate “landing pages” for each clinic or division would be built within the app.

 Different sections of the smartphone app will include:

  • Healthcare team members: This would include the multi-disciplinary healthcare team’s pictures and short biographies. The information listed here could be similar to that of existing paper provider facecards.
  • Common conditions / diseases: This would include information on common conditions /diseases that are treated by that particular clinic or inpatient medical team as well as the usual, expected treatment plan. This section will require vetting from clinical liaisons to ensure accurate information and will also need to be written at an appropriate patient literacy level.
  • My Treatment Timeline: This section would outline pending lab or imaging tests that their provider(s) have ordered as well as the timeline for completion of the tests. Active medications would also be listed here.
  • Contact information for clinic or nursing station
  • Nearby ATMs, restaurants, pharmacies
  • Directory of Hospital / Clinic Services: This would include brief descriptions and contact information for spiritual care, café/cafeteria hours, gift shop hours, interpreter services, and service excellence.
  • Patient Notes: This would be an area where patients can record healthcare provider voice instructions or take pictures using technology already on all smart phones.
  • MyChart: A direct link to MyChart to allow users to access their medical record.

Feasibility:

As mentioned above, a very similar smartphone app has already been developed and built with the direct input of patients and families at UCLA and can be downloaded at this link: https://itunes.apple.com/us/app/ucla-neurosurgery/id1056278075?mt=8. We have relationships with individuals at UCLA who were involved in building and launching the app, and can help ensure that the UCSF build team does not have to start from scratch in this ambitious project.

Linking APeX to the app to allow for “My Treatment Timeline” and “MyChart” sections above may be a harder challenge, but has been done at UCLA with success.

Lastly, there will need to be a publicity campaign to ensure that patients and families are aware of the app.

Evaluation:

We propose implementing this technology as a randomized control trial that would involve inpatient medicine teams and ambulatory clinics that wish to participate. Teams and clinics would be randomized over a 3-6 month period with half promoting the use of the UCSF Health smartphone app while the other half would continue to promote the use of MyChart alone (existing standard of care). We would collect qualitative outcomes of patient/family and provider survey data and quantitative outcomes using HCAHPS and CGCAHPs Likelihood to Recommend Scores.  If a RCT is not feasible to implement, then a pre-post test design will be used. 

Commenting is closed.

HOSPLIFE - Version 2.0: Bringing Hospital Information to Patients and Families Through A Web Based Mobile Application

Idea Status: 

Hospitalization and the navigation of the health system is increasingly complex - those hospitalized need an easy to use tool to outline the hospital journey from admission to discharge and care at home. While some of this information can be found on the UCSF web-site, paper documents, and in verbal conversation with staff - a web based mobile application can serve as an easy to use reference or introduction to concepts not previously explained to patients - like what to expect at time of discharge.

Over the past 18 months with support from local grant funding and use of a third party developer, our team has created version 1.0 of HospLife and performed pilot testing. Version 2.0, will add features and enhancements based on user input. We envision this tool can empower patient and family members and be customizable to specific patient populations within the Department of Medicine and the larger health system.

Commenting is closed.

UCSF Shuttle BioCourier - Mobile App/GPS Shuttle Specimen Transport

Idea Status: 

Current Challenges

We used to be able to place patient samples (primarily blood and tissue specimens from hospitals/clinics) and research samples between campuses using the existing shuttle system. This presumably has been halted since shuttle drivers cannot be held responsible for the potentially biohazardous contents of any packages and the subsequent procedures for handling the samples should something happen during transit. The halting of this resource has placed the task of specimen/sample delivery on lab technicians, clinical research coordinators and other researchers. This amounts to at least one full hour of lost productivity for each delivery (to and from the site of origin), creating an enormous personnel burden for the university staff.

 

Mobile App Based Solution

If a mobile app were to link the UCSF database of training history with the GPS location of a participating shuttle rider, the occupied shuttle could now be tagged as active for sample transport. The app would require UCSF personnel to sign up, linking their training history to their username and enabling GPS features of their mobile device. App usability would be broken into two phases: a data acquisition phase and a rider input phase. The data acquisition phase would simply utilize participants shuttle activity and training history to build a database of statistics on shuttle routes. This data would give you a percentage chance of each shuttle route being active for transport, defined by having at least one rider that is certified for handling biological specimens. UCSF would have to provide some basic incentive for downloading the BioCourier App, or simply incorporate this first phase of data collection using the existing UCSF mobile app. The second phase would begin to involve rider input. This would allow a rider to let the app know that they were about to ride a shuttle. This would raise certainty of shuttle activation to 100% and allow other researchers to plan their shipments more effectively. The timing of a passenger notifying the app of a ride is essential to labs getting notification for dropping off the specimens, so an incentive from UCSF would have to be involved to motivate users to accurately report their rides ahead of time. An accuracy rating for each user would be reported by the app so that potential shippers could see the likelihood that a rider would actually be present on the shuttle. This phase would work in tandem with the first phase, so if someone were to fail to show for a shuttle ride they activated, it could still be activated by another rider and the odds of that happening would be reported to the shipper. Incentives could include anything from discounted coffee and food on campus to bonuses through UCSF resources such as gym membership. If the app is well designed from a UX perspective, participation level required to ensure functionality would be quite low and alleviate a substantial personnel strain on labs and clinical research teams. Initial discussions with numerous PIs suggest that this sort of system would be enthusiastically and widely utilized across the university.

 

Commenting is closed.

Ambulatory monitoring devices: expanding care beyond the office walls

Idea Status: 

Objective

To use ambulatory monitoring devices so that:

  1. providers can more closely monitor at-risk, high-utilizing (or all) patients
  2. patients have greater, more timely access to health care and advice
  3. high risk patients can avoid worse outcomes

Background

We often ask patient with heart failure (daily weights) and diabetes (blood glucose) to collect frequent clinical data that providers only analyze every few months. This results in many missed opportunities to intervene on patients who have poor control of their illnesses. 

As the healthcare system evolves, the office visit becomes highly valued real estate. Interactions with healthcare providers need to be high yield and care that can be provided by other members of the healthcare team or in other settings will likely move to being provided in those ways.

Brief description of intervention

In many regards, this is similar to the “HIPSTER” proposal but expanded for other diseases that can use this model.

Heart failure:

Heart failure is one of the most common causes of readmission. Due to changes in Center for Medicare and Medicaid Services reimbursement models, hospitals have begun to feel financial pressure from high readmission rates. While some patients have disease that cannot be well managed in the outpatient setting, there are many who don’t know how to manage their disease well as an outpatient.

This proposal focuses on providing a subset of patients with heart failure with a scale that automatically records and sends the patient’s weight to his/her providers. This device could also be synced with this patient’s cell phone, email, and/or landline. This would enable primarily two interventions:

If the patient’s weight exceeded set parameters dictated by the patient’s providers:

a)     an automatic reminder would be sent (via SMS, email, and/or automated phone call) to increase the patient’s diuretic dose (much in the same way that providers currently provide instructions)

b)     a notification could be sent to designated team members to check in with the patient and determine a need for a face-to-face encounter

Diabetes

We also often ask our patients with diabetes to check their blood sugars on a frequent basis. We then review this data every three months and provide suggestions about how to better control a patient’s sugar. As we move towards a bundled payment system, this will become an increasingly poor use of the face-to-face time between patients and providers. This is especially true if at least some of the teaching and instruction can be provided outside an in-person interaction.

This proposal suggests providing a subset of patients with diabetes with blood glucose monitors that automatically record and send this data to the patient’s providers. This device could also be synced with this patient’s own cell phone, email, and/or landline. This would enable again two similar interventions:

a)     patients could receive suggested insulin titration doses via email, SMS, or phone call based on automated insulin titration that could be pre-approved by a patient’s provider

b)     patients with blood glucoses outside a designated range (either too high or too low) would receive a reach-out phone call from a provider

References

Levy N, Moynihan V, Nilo A, Singer K, Bernik LS, Etiebet MA, Fang Y, Cho J, Natarajan S. The Mobile Insulin Titration Intervention (MITI) for Insulin Adjustment in an Urban, Low-Income Population: Randomized Controlled Trial. J Med Internet Res 2015;17(7):e180. http://www.jmir.org/2015/7/e180/

 

Kulnik et al. Evaluation of Implementation of a Fully Automated Algorithm (Enhanced Model Predictive Control) in an Interacting Infusion Pump System for Establishment of Tight Glycemic Control in Medical Intensive Care Unit Patients. J Diabetes Sci Technol 2008; 2(6): 963-970. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769812/

 

Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.: CD007228. DOI: 10.1002/14651858.CD007228.pub2.

Commenting is closed.

Bridging the gap to providing care for LEP (Limited English Proficiency) patients

Idea Status: 

Objective

To create patient education materials and handouts for patients in their native language.

Background

San Francisco has an incredibly diverse population. Census data shows that approximately 45% of households have a language other than English spoken at home.  Nearly 30% of these households identify as speaking English “not well” or “not at all” resulting in approximately 1 out of 8 San Francisco residents identifying as having limited English proficiency (LEP)

Brief description of intervention

Despite the prevalence of LEP patients in our city, the patient education materials that we distribute to patients are often given only in English. This includes:

a)     the patient instructions and education materials when patients are discharged from the hospital

b)     the after visit summary given after outpatient visits

c)     the entire MyChart interface

d)     letters mailed to patients

e)     advanced directive forms available for inpatients at UCSF

Given the availability of automatic translation tools (granted of varying quality), we should be doing much better at delivering patients language concordant information. This proposal aims to identify better ways to provide patients materials in their native written language. This effort could be implemented in many ways

a)     As an consideration in all new projects (including many of the proposed projects on this site) such as:

                        i.         the PREPARE project (providing multiple language guidance through advanced care planning)

                       ii.         the automatic dictation of visit summary project

b)     As an addition/revision of already existing resources including the ones listed above (patient education materials, after visit summary, mailings to patients)

In terms of implementation, there would be a number of potential approaches including:

a)     Automatic translation of English words typed by a provider (much like how Google does)

b)     A dictionary of common phrases that are already translated into the three to five most common languages. These can be used by providers trying to communicate common instructions / directions

c)     Translating many of our already existing patient education and informational materials (or finding similar ones already in the patient’s language) and making it accessible in Apex to providers trying to provide patient education whether in the discharge instructions, patient's after visit summary, or via MyChart

Commenting is closed.

A More Patient Driven, Accurate Medication Reconciliation

Idea Status: 

Objective

To create a way of collecting a more accurate medication reconciliation in a less time intensive way

Background

In medicine, much of the care we provide is very dependent on a patient’s adherence to the (often complicated) medication regimen we prescribe. Understanding what medications a patient is taking is therefore crucial to helping us understand how we can better improve their health outcomes.

On the inpatient medicine side, an admission medication reconciliation is vital to ensuring that the patient does not experience adverse outcomes from us misunderstanding what medications a patient was taking at home. However, collecting this information is exceptionally time consuming and oftentimes patients are unable to provide the necessary information.

Outpatient providers also want to know what the patient is taking. Despite the information listed in the electronic medical record, patients are often taking medications in a way quite disparate from what providers envision based on reading a chart.

 Brief description of intervention

I propose the creation of an integrated medication reconciliation tool that will allow both inpatient and outpatient providers to capture exactly what medications the patient is taking and how they are taking these medications. The ideal version of this application or program would require limited time on the providers part and instead would be very much patient--or patient’s family--driven

This application would have a number of features:

a)     For collecting medication names, this program could:

  • pull information from the electronic medical record and/or SureScripts so that there is some information for the patient to go off from prior to starting the med rec
  • allow for medication input via pictures of the medication bottles or pills
  • allow patients to select medications based on pictures compiled from already existing databases

b)     For collecting information about frequency, timing, and dosage of medication ingestion, patients could

  • Select a time of day when they take each medication
  • Indicate if they take the medication with food

Much in the same way that the “Discharge medication regimen made easier” proposal nicely describes, I envision that when doing this, the patient would drag pictures of their medication pills with names into grids for morning, noon, evening, and bedtime. (Imagine what a pharmacist might do when blister packing medications.)

This information could be collected from patients independently while they wait to be seen by a provider in either an outpatient or inpatient setting. Thus this vital time is not wasted when the patient and provider finally connect.

Requesting patients to also place their medications into one of these four time slots can hopefully also reinforce grouping of medications to increased medication adherence (much like the universal medication schedule is designed to do). 

Commenting is closed.