ABSTRACT
BACKGROUND: The transformation of health care during COVID-19, with the rapid expansion of telemedicine visits, presents new challenges to chronic care and preventive health providers. Clinical decision support (CDS) is critically important to chronic care providers, and CDS malfunction is common during times of change. It is essential to regularly reassess an organization's ambulatory CDS program to maintain care quality. This is especially true after an immense change, like the COVID-19 telemedicine expansion. OBJECTIVE: Our objective is to reassess the ambulatory CDS program at a large academic medical center in light of telemedicine's expansion in response to the COVID-19 pandemic. METHODS: Our clinical informatics team devised a practical framework for an intrapandemic ambulatory CDS assessment focused on the impact of the telemedicine expansion. This assessment began with a quantitative analysis comparing CDS alert performance in the context of in-person and telemedicine visits. Board-certified physician informaticists then completed a formal workflow review of alerts with inferior performance in telemedicine visits. Informaticists then reported on themes and optimization opportunities through the existing CDS governance structure. RESULTS: Our assessment revealed that 10 of our top 40 alerts by volume were not firing as expected in telemedicine visits. In 3 of the top 5 alerts, providers were significantly less likely to take action in telemedicine when compared to office visits. Cumulatively, alerts in telemedicine encounters had an action taken rate of 5.3% (3257/64,938) compared to 8.3% (19,427/233,636) for office visits. Observations from a clinical informaticist workflow review included the following: (1) Telemedicine visits have different workflows than office visits. Some alerts developed for the office were not appearing at the optimal time in the telemedicine workflow. (2) Missing clinical data is a common reason for the decreased alert firing seen in telemedicine visits. (3) Remote patient monitoring and patient-reported clinical data entered through the portal could replace data collection usually completed in the office by a medical assistant or registered nurse. CONCLUSIONS: In a large academic medical center at the pandemic epicenter, an intrapandemic ambulatory CDS assessment revealed clinically significant CDS malfunctions that highlight the importance of reassessing ambulatory CDS performance after the telemedicine expansion.
ABSTRACT
Background: Diabetes prevalence continues to be a concern and the management of diabetes is important but costly. The prevalence of diabetes is greater among persons with a low income, including those who are uninsured or underinsured. Student-run free clinics (SRFC) are one resource to these patients who may otherwise lack access to medical care. Objective: The purpose of this study was to assess patient satisfaction with diabetes care at a SRFC in order to assist in identifying areas of improvement. Methods: A quality improvement survey was designed to assess patient satisfaction with overall care, as well as with routines and perception of care related to self-management, healthy eating, and exercise. Results: The survey was completed by 25 patients at a Toledo area SRFC. Established patients who were aged 18 years or older and diagnosed with diabetes, were invited to complete the survey. The majority of patients were satisfied with their diabetes care at the SRFC (88%). Fewer patients, however, reported satisfaction with the treatment for their diabetes (72%) and with their knowledge about diabetes (76%). Subanalyses of survey responses also showed significant differences when comparing sex, age, and length of diabetes diagnosis. Conclusions: The survey helped identify key areas in which the diabetes care provided at the SRFC could be improved. These areas included education about diabetes in general, as well as in understanding treatment, self-monitoring, and healthy eating and exercise options. Future research could explore survey results after specifying and implementing changes made to the education provided to the patients.
