Assisted reproductive technology (ART) patient information-seeking behavior: a qualitative study.

BACKGROUND: Approximately 13% of women in the United States of reproductive age seek infertility services. Assisted reproductive technology (ART), including in vitro fertilization, is used to help patients achieve pregnancy. Many people are not familiar with these treatments prior to becoming patients and possess knowledge gaps about care. METHODS: This study employed qualitative methods to investigate how patients interact with information sources during care. Patients who underwent ART including embryo transfer between January 2017 and April 2022 at a large urban healthcare center were eligible. Semi-structured, in-depth interviews were conducted between August and October 2022. Fifteen females with an average age of 39 years participated. Reflexive thematic analysis was performed. RESULTS: Two main themes emerged. Participants (1) utilized clinic-provided information and then turned to outside sources to fill knowledge gaps; (2) struggled to learn about costs, insurance, and mental health resources to support care. Participants preferred clinic-provided resources and then utilized academic sources, the internet, and social media when they had unfulfilled information needs. Knowledge gaps related to cost, insurance, and mental health support were reported. CONCLUSION: ART clinics can consider providing more information about cost, insurance, and mental health support to patients. TRIAL REGISTRATION: The Massachusetts General Hospital Institutional Review Board approved this study (#2022P000474) and informed consent was obtained from each participant.

A Pilot Randomized Controlled Trial of Augmented Reality Just-in-Time Guidance for the Performance of Rugged Field Procedures.

INTRODUCTION: Medical resuscitations in rugged prehospital settings require emergency personnel to perform high-risk procedures in low-resource conditions. Just-in-Time Guidance (JITG) utilizing augmented reality (AR) guidance may be a solution. There is little literature on the utility of AR-mediated JITG tools for facilitating the performance of emergent field care. STUDY OBJECTIVE: The objective of this study was to investigate the feasibility and efficacy of a novel AR-mediated JITG tool for emergency field procedures. METHODS: Emergency medical technician-basic (EMT-B) and paramedic cohorts were randomized to either video training (control) or JITG-AR guidance (intervention) groups for performing bag-valve-mask (BVM) ventilation, intraosseous (IO) line placement, and needle-decompression (Needle-d) in a medium-fidelity simulation environment. For the interventional condition, subjects used an AR technology platform to perform the tasks. The primary outcome was participant task performance; the secondary outcomes were participant-reported acceptability. Participant task score, task time, and acceptability ratings were reported descriptively and compared between the control and intervention groups using chi-square analysis for binary variables and unpaired t-testing for continuous variables. RESULTS: Sixty participants were enrolled (mean age 34.8 years; 72% male). In the EMT-B cohort, there was no difference in average task performance score between the control and JITG groups for the BVM and IO tasks; however, the control group had higher performance scores for the Needle-d task (mean score difference 22%; P = .01). In the paramedic cohort, there was no difference in performance scores between the control and JITG group for the BVM and Needle-d tasks, but the control group had higher task scores for the IO task (mean score difference 23%; P = .01). For all task and participant types, the control group performed tasks more quickly than in the JITG group. There was no difference in participant usability or usefulness ratings between the JITG or control conditions for any of the tasks, although paramedics reported they were less likely to use the JITG equipment again (mean difference 1.96 rating points; P = .02). CONCLUSIONS: This study demonstrated preliminary evidence that AR-mediated guidance for emergency medical procedures is feasible and acceptable. These observations, coupled with AR's promise for real-time interaction and on-going technological advancements, suggest the potential for this modality in training and practice that justifies future investigation.

Examining Diurnal Differences in Multidisciplinary Care Teams at a Pediatric Trauma Center Using Electronic Health Record Data: Social Network Analysis.

BACKGROUND: The care of pediatric trauma patients is delivered by multidisciplinary care teams with high fluidity that may vary in composition and organization depending on the time of day. OBJECTIVE: This study aims to identify and describe diurnal variations in multidisciplinary care teams taking care of pediatric trauma patients using social network analysis on electronic health record (EHR) data. METHODS: Metadata of clinical activities were extracted from the EHR and processed into an event log, which was divided into 6 different event logs based on shift (day or night) and location (emergency department, pediatric intensive care unit, and floor). Social networks were constructed from each event log by creating an edge among the functional roles captured within a similar time interval during a shift. Overlapping communities were identified from the social networks. Day and night network structures for each care location were compared and validated via comparison with secondary analysis of qualitatively derived care team data, obtained through semistructured interviews; and member-checking interviews with clinicians. RESULTS: There were 413 encounters in the 1-year study period, with 65.9% (272/413) and 34.1% (141/413) beginning during day and night shifts, respectively. A single community was identified at all locations during the day and in the pediatric intensive care unit at night, whereas multiple communities corresponding to individual specialty services were identified in the emergency department and on the floor at night. Members of the trauma service belonged to all communities, suggesting that they were responsible for care coordination. Health care professionals found the networks to be largely accurate representations of the composition of the care teams and the interactions among them. CONCLUSIONS: Social network analysis was successfully used on EHR data to identify and describe diurnal differences in the composition and organization of multidisciplinary care teams at a pediatric trauma center.

Physician Perceptions of the Electronic Problem List in Pediatric Trauma Care.

OBJECTIVE: To describe physician perceptions of the potential goals, characteristics, and content of the electronic problem list (PL) in pediatric trauma. METHODS: We conducted 12 semistructured interviews with physicians involved in the pediatric trauma care process, including residents, fellows, and attendings from four services: emergency medicine, surgery, anesthesia, and pediatric critical care. Using qualitative content analysis, we identified PL goals, characteristics, and patient-related information from these interviews and the hospital's PL etiquette document of guideline. RESULTS: We identified five goals of the PL (to document the patient's problems, to make sense of the patient's problems, to make decisions about the care plan, to know who is involved in the patient's care, and to communicate with others), seven characteristics of the PL (completeness, efficiency, accessibility, multiple users, organized, created before arrival, and representing uncertainty), and 22 patient-related information elements (e.g., injuries, vitals). Physicians' suggested criteria for a PL varied across services with respect to goals, characteristics, and patient-related information. CONCLUSION: Physicians involved in pediatric trauma care described the electronic PL as ideally more than a list of a patient's medical diagnoses and injuries. The information elements mentioned are typically found in other parts of the patient's electronic record besides the PL, such as past medical history and labs. Future work is needed to evaluate the optimal design of the PL so that users with emergent cases, such as pediatric trauma, have access to key information related to the patient's immediate problems.

Mapping the Flow of Pediatric Trauma Patients Using Process Mining.

BACKGROUND: Inhospital pediatric trauma care typically spans multiple locations, which influences the use of resources, that could be improved by gaining a better understanding of the inhospital flow of patients and identifying opportunities for improvement. OBJECTIVES: To describe a process mining approach for mapping the inhospital flow of pediatric trauma patients, to identify and characterize the major patient pathways and care transitions, and to identify opportunities for patient flow and triage improvement. METHODS: From the trauma registry of a level I pediatric trauma center, data were extracted regarding the two highest trauma activation levels, Alpha (n = 228) and Bravo (n = 1,713). An event log was generated from the admission, discharge, and transfer data from which patient pathways and care transitions were identified and described. The Flexible Heuristics Miner algorithm was used to generate a process map for the cohort, and separate process maps for Alpha and Bravo encounters, which were assessed for conformance when fitness value was less than 0.950, with the identification and comparison of conforming and nonconforming encounters. RESULTS: The process map for the cohort was similar to a validated process map derived through qualitative methods. The process map for Bravo encounters had a relatively low fitness of 0.887, and 96 (5.6%) encounters were identified as nonconforming with characteristics comparable to Alpha encounters. In total, 28 patient pathways and 20 care transitions were identified. The top five patient pathways were traversed by 92.1% of patients, whereas the top five care transitions accounted for 87.5% of all care transitions. A larger-than-expected number of discharges from the pediatric intensive care unit (PICU) were identified, with 84.2% involving discharge to home without the need for home care services. CONCLUSION: Process mining was successfully applied to derive process maps from trauma registry data and to identify opportunities for trauma triage improvement and optimization of PICU use.

Linking Electronic Health Record and Trauma Registry Data: Assessing the Value of Probabilistic Linkage.

BACKGROUND: Electronic health record (EHR) systems contain large volumes of novel heterogeneous data that can be linked to trauma registry data to enable innovative research not possible with either data source alone. OBJECTIVE: This article describes an approach for linking electronically extracted EHR data to trauma registry data at the institutional level and assesses the value of probabilistic linkage. METHODS: Encounter data were independently obtained from the EHR data warehouse (n = 1,632) and the pediatric trauma registry (n = 1,829) at a Level I pediatric trauma center. Deterministic linkage was attempted using nine different combinations of medical record number (MRN), encounter identity (ID) (visit ID), age, gender, and emergency department (ED) arrival date. True matches from the best performing variable combination were used to create a gold standard, which was used to evaluate the performance of each variable combination, and to train a probabilistic algorithm that was separately used to link records unmatched by deterministic linkage and the entire cohort. Additional records that matched probabilistically were investigated via chart review and compared against records that matched deterministically. RESULTS: Deterministic linkage with exact matching on any three of MRN, encounter ID, age, gender, and ED arrival date gave the best yield of 1,276 true matches while an additional probabilistic linkage step following deterministic linkage yielded 110 true matches. These records contained a significantly higher number of boys compared to records that matched deterministically and etiology was attributable to mismatch between MRNs in the two data sets. Probabilistic linkage of the entire cohort yielded 1,363 true matches. CONCLUSION: The combination of deterministic and an additional probabilistic method represents a robust approach for linking EHR data to trauma registry data. This approach may be generalizable to studies involving other registries and databases.

Usability evaluation of an emergency department information system prototype designed using cognitive systems engineering techniques.

This article presents an evaluation of novel display concepts for an emergency department information system (EDIS) designed using cognitive systems engineering methods. EDISs assist emergency medicine staff with tracking patient care and ED resource allocation. Participants performed patient planning and orientation tasks using the EDIS displays and rated the display's ability to support various cognitive performance objectives along with the usability, usefulness, and predicted frequency of use for 18 system components. Mean ratings were positive for cognitive performance support objectives, usability, usefulness, and frequency of use, demonstrating the successful application of design methods to create useful and usable EDIS concepts that provide cognitive support for emergency medicine staff. Nurse and provider roles had significantly different perceptions of the usability and usefulness of certain EDIS components, suggesting that they have different information needs while working.

Communication in the Electronic Age: an Analysis of Face-to-Face Physician-Nurse Communication in the Emergency Department.

We describe the patterns and content of nurse to physician verbal conversations in three emergency departments (EDs) with electronic health records. Emergency medicine physicians and nurses were observed for 2 h periods. Researchers used paper notes to document the characteristics (e.g., partners involved, location of communication, who initiated communication) and content of nurse to physician conversations. Eighteen emergency nurses and physicians (nine each) were observed for a total of 36 h. Two hundred and fifty-five unique communication events were recorded across three emergency departments spread evenly across day, evening, and night shifts. A qualitative analysis of communication event content revealed 5 types of communication and 13 content themes. Content themes covered a broad range of topics including exchange of patient health information, management of the ED, and coordination of orders. Physician participants experienced significantly more communication events than nurse participants, while nurses initiated significantly more communication events than physicians. Most of the communication events occurred at the physician workstation followed by patient treatment areas. This study describes nature of verbal nurse to physician communication in the ED. Direct communication is still used to communicate important information, such as information about patients' status, in EDs with established electronic health records. Our results provide an overview of information exchanged in the ED which can serve as a basis for designing improved information support systems.

Assessment of Innovative Emergency Department Information Displays in a Clinical Simulation Center.

The objective of this work was to assess the functional utility of new display concepts for an emergency department information system created using cognitive systems engineering methods, by comparing them to similar displays currently in use. The display concepts were compared to standard displays in a clinical simulation study during which nurse-physician teams performed simulated emergency department tasks. Questionnaires were used to assess the cognitive support provided by the displays, participants' level of situation awareness, and participants' workload during the simulated tasks. Participants rated the new displays significantly higher than the control displays in terms of cognitive support. There was no significant difference in workload scores between the display conditions. There was no main effect of display type on situation awareness, but there was a significant interaction; participants using the new displays showed improved situation awareness from the middle to the end of the session. This study demonstrates that cognitive systems engineering methods can be used to create innovative displays that better support emergency medicine tasks, without increasing workload, compared to more standard displays. These methods provide a means to develop emergency department information systems-and more broadly, health information technology-that better support the cognitive needs of healthcare providers.

The impact of interoperability of electronic health records on ambulatory physician practices: a discrete-event simulation study.

BACKGROUND: The effect of health information technology (HIT) on efficiency and workload among clinical and nonclinical staff has been debated, with conflicting evidence about whether electronic health records (EHRs) increase or decrease effort. None of this paper to date, however, examines the effect of interoperability quantitatively using discrete event simulation techniques. OBJECTIVE: To estimate the impact of EHR systems with various levels of interoperability on day-to-day tasks and operations of ambulatory physician offices. METHODS: Interviews and observations were used to collect workflow data from 12 adult primary and specialty practices. A discrete event simulation model was constructed to represent patient flows and clinical and administrative tasks of physicians and staff members. RESULTS: High levels of EHR interoperability were associated with reduced time spent by providers on four tasks: preparing lab reports, requesting lab orders, prescribing medications, and writing referrals. The implementation of an EHR was associated with less time spent by administrators but more time spent by physicians, compared with time spent at paper-based practices. In addition, the presence of EHRs and of interoperability did not significantly affect the time usage of registered nurses or the total visit time and waiting time of patients. CONCLUSION: This paper suggests that the impact of using HIT on clinical and nonclinical staff work efficiency varies, however, overall it appears to improve time efficiency more for administrators than for physicians and nurses.