Implementation to Optimization: A Tailored, Data-Driven Approach to Improve Provider Efficiency and Confidence in Use of the Electronic Medical Record.

PURPOSE: Nine months after the implementation of a new electronic medical record (EMR) system at a single institution, physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs) expressed frustration with its use. We aimed to test if an individually tailored training approach reduced time spent with the EMR and increased confidence. MATERIALS AND METHODS: Two hours of training were conducted in a one-on-one manner with a trainer. Content was individualized according to the following: provider survey, EMR utilization profile, and shadowing in clinic. Surveys assessed confidence before training and immediately after training. Changes in time spent in various EMR activities before training and after training were compared. RESULTS: Three trainers delivered one-on-one training to 133 MDs, 42 NPs, and 10 PAs who specialized in medical oncology. Participants reported an increase in confidence across all activities, and almost all providers (98%) who responded to our survey agreed that the training enhanced their efficiency. A non-statistically significant trend toward reduction in the overall time in the system was observed. Time in system was reduced primarily in activities such as documentation and ordering of laboratory tests, imaging, medications, and chemotherapy. CONCLUSION: A personalized and data-driven training approach was highly regarded by providers. EMR usage reports provided extensive data to identify and prioritize training content and were valuable to measure the impact of training on provider time in system. With the growth of EMR implementation and the reported relationship of EMR use to burnout, continuous and personalized training after EMR implementation is effective to reduce the time in system and increase confidence.

Measuring Chemotherapy Appointment Duration and Variation Using Real-Time Location Systems.

INTRODUCTION: Clinical schedules drive resource utilization, cost, and patient wait time. Accurate appointment duration allocation ensures appropriate staffing ratios to daily caseloads and maximizes scarce resources. Dana-Farber Cancer Institute (DFCI) infusion appointment duration is adjusted by regimen using a consensus method of experts including pharmacists, nurses, and administrators. Using real-time location system (RTLS), we examined the accuracy of observed appointment duration compared with the scheduled duration. METHODS: Appointment duration was calculated using RTLS at DFCI between August 1, 2013, and September 30, 2013. Duration was defined as the total time a patient occupied an infusion chair. The top 10 administered infusion regimens were investigated (n = 805). RESULTS: Median observed appointment durations were statistically different than the scheduled durations. Appointment durations were shorter than scheduled 98% (C), 95% (I), and 75% (F) of the time and longer than scheduled 77% (A) and 76% (G) of the time. Fifty-six percent of the longer than scheduled (A) appointments were at least 30 minute longer. CONCLUSION: RTLS provides reliable and unbiased data to improve schedule accuracy. Replacing consensus with system-based data may improve clinic flow, relieve staff stress, and increase patient satisfaction. Further investigation is warranted to elucidate factors that impact variation in appointment duration.

Variation in Additional Breast Imaging Orders and Impact on Surgical Wait Times at a Comprehensive Cancer Center.

BACKGROUND: In the multidisciplinary care model, breast imagers frequently provide second-opinion reviews of imaging studies performed at outside institutions. However, the need for additional imaging and timeliness of obtaining these studies has yet to be established. We sought to evaluate the frequency of additional imaging orders by breast surgeons and to evaluate the impact of this supplementary imaging on timeliness of surgery. METHODS: We identified 2489 consecutive women with breast cancer who underwent first definitive surgery (FDS) at our comprehensive cancer center between 2011 and 2013. The number of breast-specific imaging studies performed for each patient between initial consultation and FDS was obtained. χ (2) tests were used to quantify the proportion of patients undergoing additional imaging by surgeon. Interval time between initial consultation and additional imaging and/or biopsy was calculated. The delay of additional imaging on time to FDS was assessed by t test. RESULTS: Of 2489 patients, 615 (24.7 %) had at least one additional breast-specific imaging study performed between initial consultation and FDS, with 222 patients undergoing additional biopsies (8.9 %). The proportion of patients receiving imaging tests by breast surgeon ranged from 15 to 39 % (p < 0.0001). Patients receiving additional imaging had statistically longer wait times to FDS for BCT (21.4-28.5 days, p < 0.0001). CONCLUSIONS: Substantial variability exists in the utilization of additional breast-specific imaging and in the timeliness of obtaining these tests among breast surgeons. Further research is warranted to assess the sources and impact of this variation on patient care, cost, and outcomes.

Understanding process-of-care delays in surgical treatment of breast cancer at a comprehensive cancer center.

Few studies have examined care processes within providers' and institutions' control that expedite or delay care. The authors investigated the timeliness of breast cancer care at a comprehensive cancer center, focusing on factors influencing the time from initial consultation to first definitive surgery (FDS). The care of 1,461 women with breast cancer who underwent surgery at Dana-Farber/Brigham and Women's Cancer Center from 2011 to 2013 was studied. The interval between consultation and FDS was calculated to identify variation in timeliness of care based on procedure, provider, and patients' sociodemographic characteristics. Targets of 14 days for lumpectomy and mastectomy and 28 days from mastectomy with immediate reconstruction were set and used to define delay. Mean days between consultation and FDS was 21.6 (range 1-175, sd 15.8) for lumpectomy, 36.7 (5-230, 29.1) for mastectomy, and 37.5 (7-111, 16) for mastectomy with reconstruction. Patients under 40 were less likely to be delayed (OR = 0.56, 95 % CI = 0.33-0.94, p = 0.03). Patients undergoing mastectomy alone (OR = 2.64, 95 % CI = 1.80-3.89, p < 0.0001) and mastectomy with immediate reconstruction (OR = 1.34 95 % CI = 1.00-1.79, p = 0.05) were more likely to be delayed when compared to lumpectomy. Substantial variation in surgical timeliness was identified. This study provides insight into targets for improvement including better coordination with plastic surgery and streamlining pre-operative testing. Cancer centers may consider investing in efforts to measure and improve the timeliness of cancer care.

Measuring opportunities to improve timeliness of breast cancer care at Dana-Farber/Brigham and Women's Cancer Center.

The authors sought to measure the timeliness of care for patients with breast cancer at Dana-Farber/Brigham and Women's Cancer Center throughout the treatment continuum, and to identify sources of variation that may serve as targets for improving care delivery. This report describes the methods that were developed to measure and analyze baseline performance.