Health Informatics Workforce in the Digital Health Ecosystem.

Workforce development needs to align with the healthcare data ecosystem emerging from digital transformation in healthcare. Careers for health informaticists are emerging as translational agents between clinicians and data scientists. Digital tools and mechanisms in healthcare, through electronic health records (EHR), devices, capabilities including artificial intelligence (AI), machine learning (ML), interoperability and health information exchange (HIE) allow clinicians and stakeholders to capture, store, access and use health data and information in ways unseen in years past, creating a new digital health ecosystem. This transformation is evolving both technologies and the strategies to influence health outcomes. Careers in health informatics are now part of this data ecosystem, and it is important to examine the current status and its implications for job seekers and for workforce development.

Improving the efficiency of virtual insulin teaching for patients admitted to hospital through the COVID-19 pandemic: a quality improvement initiative.

BACKGROUND: Throughout the COVID-19 pandemic, many areas of medicine transitioned to virtual care. For patients with diabetes admitted to hospital, this included diabetes education and insulin teaching. Shifting to a virtual model of insulin teaching created new challenges for inpatient certified diabetes educators (CDE). OBJECTIVE: We advanced a quality improvement project to improve the efficiency of safe and effective virtual insulin teaching throughout the COVID-19 pandemic. Our primary aim was to reduce the mean time between CDE referral to successful inpatient insulin teach by 0.5 days. DESIGN, SETTING, PARTICIPANTS: We conducted this initiative at two large academic hospitals between April 2020 and September 2021. We included all admitted patients with diabetes who were referred to our CDE for inpatient insulin teaching and education. INTERVENTION: Alongside a multidisciplinary team of project stakeholders, we created and studied a CDE-led, virtual (video conference or telephone) insulin teaching programme. As tests of change, we added a streamlined method to deliver insulin pens to the ward for patient teaching, created a new electronic order set and included patient-care facilitators in the scheduling process. MAIN OUTCOME AND MEASURES: Our main outcome measure was the mean time between CDE referral and successful insulin teach-back. Our process measure was the percentage of successful insulin pen deliveries to the ward for teaching. As balance measures, we captured the percentage of patients with a successful insulin teach, the time between insulin teach and hospital discharge, and readmissions to hospital for diabetes-related complications. RESULTS: Our tests of change improved the efficiency of safe and effective virtual insulin teaching by 0.27 days. The virtual model appeared less efficient than usual in-person care. CONCLUSIONS: In our centre, virtual insulin teaching supported patients admitted to hospital through the pandemic. Improving the administrative efficiency of virtual models and leveraging key stakeholders remain important for long-term sustainability.

Patient Safety Perception Within Hospitals: An Examination of Job Type, Handoffs and Information Exchange, and Hospital Management Support.

OBJECTIVES: The study has 3 aims: (1) to assess to what extent a person's job role relates to their evaluation of patient safety in the hospital setting; 2) to identify the relationship from hospital management aspects, including level of organizational learning-continuous improvement, level of management support, and level of leader support to patient safety perception in the hospital setting; and 3) to examine the relationship between the rating of the ease of information exchange and clinical handoffs and perceived patient safety in the hospital setting. METHODS: This study used a publicly available, deidentified cross-sectional data set from the 2021 Agency for Healthcare Research and Quality's Survey on Patient Safety Culture Hospital Survey 2.0. Welch's analysis of variance and multiple linear regression were used to examine each factor's impact on patient safety rating. RESULTS: Supervisors had a higher ( P < 0.001) patient safety perception than people in other job types, whereas nurses had a lower ( P < 0.001) patient safety perception than other job types. Level of organizational learning-continuous improvement ( P < 0.001), level of hospital management ( P < 0.001), level of leader support ( P < 0.001), and ease of handoffs and information exchange ( P < 0.001) were positively related to perceived patient safety. CONCLUSIONS: This study highlights the importance of identifying the unique issues affecting nurses and supervisors, different from other job types, that may explain their lower patient safety ratings. Findings from this study suggest that it is critical for organizations to focus on initiatives and policies that promote leadership, management, ease in information exchange and handoffs, and continuous learning.

Voluntary assisted dying in Victoria: Why knowing the law matters to nurses.

In 2017, Victoria became the first state in Australia to pass legislation permitting voluntary assisted dying. Under this law, only those people who are near the end of their lives may access voluntary assisted dying, and because many of these people require nursing care to manage the progression of their illness or their symptoms, it will invariably have an impact on nursing practice. The Victorian law includes a series of procedural steps as safeguards to ensure that the law operates as intended. To support people who choose voluntary assisted dying and to practice safely within boundaries of the law, nurses must be aware of these requirements and how they operate. However, there are often gaps in nurses' legal knowledge. This was demonstrated in an article that aimed to inform nurses about the operation of Voluntary Assisted Dying Act 2017 (Vic) but contained several errors and misstatements of the law. Our article corrects these errors and discusses how the law is intended to be applied by revisiting the fictional case of Chloe - a woman with a terminal illness who is seeking voluntary assisted dying. As the Voluntary Assisted Dying Act 2017 (Vic) also protects nurses from liability if they act in accordance with its provisions, we conclude that sound knowledge and understanding of its operation support nurses to provide the safe, comprehensive and compassionate care their patients deserve at the end of life.

Development of Voluntary Assisted Dying Training in Victoria, Australia: A Model for Consideration.

BACKGROUND: Voluntary assisted dying was legalized in Victoria, Australia in June 2019, and was the first jurisdiction internationally to legislatively mandate training for doctors conducting eligibility assessments of patients. Mandatory training was designed as a safeguard to ensure compliance within the system, so that only eligible patients would gain access to voluntary assisted dying. OBJECTIVE: This article outlines the development of training mandated for doctors prior to undertaking eligibility assessments for voluntary assisted dying. The training addressed required legal knowledge, including doctors' roles, duties and legal protections, and also provided instruction on relevant clinical skills. DESIGN: Training design was based on 2 main principles: to comprehensively impart the legal duties imposed by the legislation; and to be readily accessible for busy doctors. The law was first mapped into a curriculum, and circulated to medical colleges, societies and professional organizations as well as international experts for feedback. The training was converted into an online e-learning format and tested at a focus group of doctors. RESULTS: The training comprises 9 modules including an assessment module. While the predominant focus of the modules is on law, they also contain some clinical components and links to further resources. Modules also contain videos, case studies and interactive exercises. The assessment consists of 30 questions, selected randomly from a question bank, with a pass mark of 90%. CONCLUSION: The Victorian legislatively-mandated voluntary assisted dying training provides standardized baseline knowledge to enhance the quality and consistency of decision-making by doctors. While further evaluation of this training is needed, it may provide a model for other jurisdictions considering making voluntary assisted dying lawful.

Transitions From Acute Care to Long-Term Care: Evaluation of the Continued Access Model.

Improving communication during transitions from acute care hospitals into long-term post-acute care (LTPAC) settings is imperative for clinical staff to have the information they need to admit and care for the patient with accurate medical information provided in an efficient way. The research goals of this study are to examine the user experience of a new data sharing method, "Continued Access," a supplement to the standard summary of care, and to evaluate staff attitudes of the model on LTPAC residents' care. Clinical staff ( n = 20) from a U.S. Midwestern LTPAC setting were interviewed to give their evaluation of the new model of data access, their concerns, and ways to improve the effectiveness of the model. Respondents reported better opportunities for quality care based on improved insight and clarity around patients' medical history, medications, and tests. Strategies for integrating Continued Access into the workflow and improving quality outcomes are discussed.

Proficiency of First-Year Podiatric Medical Residents in the Use of Electronic Medical Records.

Objectives: The aim of this study was to survey podiatric residency directors to evaluate the proficiency of first-year podiatric medical residents in the use of electronic medical records and its potential impact on medical care. Methods: An online survey consisting of Likert-scale, multiple-choice, and open-ended questions was sent via email to 216 podiatric residency directors. Questions were directed toward the level of proficiency in electronic medical records expected at the beginning of residency training and the impact on patient care of residents' inexperience with electronic medical records. Results: A total of 54 of the 216 podiatric medical residency directors completed the survey. Results indicated that 70.3 percent of respondent directors expected a moderate level of proficiency in the use of electronic medical records; however, 35.2 percent indicated that less than 50 percent of the new residents had experience with electronic medical records prior to starting residency training. Only 51.5 percent of respondent directors felt that the new residents were successful or highly successful in using their hospital's electronic medical record upon arrival, but that figure increased to 98.2 percent upon completion of the first year of residency. Of importance, 29.7 percent of respondent directors reported that inexperience in electronic medical record use resulted in a more-than-average to high impact on patient care, with open-ended responses including concerns about potential HIPAA violations, data breaches, or lost data. Conclusion: Residency directors deem it important that incoming first-year residents have a basic understanding of electronic medical records and related health informatics concepts; however, in-depth knowledge is not expected because of the high number of software programs available. Nonetheless, nearly one-third of respondents reported that inexperience in electronic medical record use does have a significant impact on patient care.

Evaluation of a Diabetes Prevention Program Lifestyle Intervention in Older Adults: A Randomized Controlled Study in Three Senior/Community Centers of Varying Socioeconomic Status.

Purpose The purpose of this study is to evaluate the feasibility and effectiveness of an adapted Diabetes Prevention Program (DPP) lifestyle program, DPP Group Lifestyle Balance (GLB), delivered in 3 economically diverse senior/community centers. Methods The DPP-GLB was implemented in 3 senior/community centers in Allegheny County, PA. A 6-month delayed control intervention design was used. Participants were randomized to begin the DPP-GLB immediately (immediate) or after a 6-month delay (delayed). Adults (n = 134; mean age = 62.8 years) with BMI ≥24 kg/m2 and prediabetes and/or the metabolic syndrome took part. Weight, physical activity (PA), and diabetes and cardiovascular disease (CVD) risk factors were assessed at 6, 12, and 18 months from baseline. Results At 6 months, the immediate group demonstrated greater mean weight loss than the delayed control group as well as significantly greater improvements in PA, A1C, fasting insulin, and waist circumference. In pre-post analyses, both randomized groups showed similar success that was maintained at 18 months. Conclusions The DPP-GLB delivered in economically diverse community centers was effective in this group of older adults. These findings support provision of coverage for prevention programs in older adults at risk for diabetes/CVD, which is important considering the large number of individuals who will be Medicare eligible in the near future.

Electronic Health Records in Long-Term Care: Staff Perspectives.

As long-term post-acute care (LTPAC) settings continue to increase their adoption of electronic health records (EHRs), it is important to learn from end users currently working with the technology to identify clinical implications and opportunities to improve systems and surrounding processes. This study utilized one-on-one interviews of direct care nurses ( n = 20) in a Midwest United States LTPAC setting to describe patterns of use, and areas to improve. The majority of respondents evaluated the EHR as easy to use, with a positive impact on quality of care, through efficiencies gained in communication with the care team. Staff responses outline desired modifications to the software, including fixes to data fields for more accurate medication administration and accurate reports on bowel protocol follow-up. Recommendations for LTPAC organizations are made regarding improved staff training on the EHR, and modifications to the EHR and related processes to improve quality of care and staff retention.

Increasing EHR system usability through standards: Conformance criteria in the HL7 EHR-system functional model.

Though substantial work has been done on the usability of health information technology, improvements in electronic health record system (EHR) usability have been slow, creating frustration, distrust of EHRs and the use of potentially unsafe work-arounds. Usability standards could be part of the solution for improving EHR usability. EHR system functional requirements and standards have been used successfully in the past to specify system behavior, the criteria of which have been gradually implemented in EHR systems through certification programs and other national health IT strategies. Similarly, functional requirements and standards for usability can help address the multitude of sequelae associated with poor usability. This paper describes the evidence-based functional requirements for usability contained in the Health Level Seven (HL7) EHR System Functional Model, and the benefits of open and voluntary EHR system usability standards.

Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease.

OBJECTIVE: To determine whether an evidence-based, behavioral lifestyle intervention program delivered at a worksite setting is effective in improving type 2 diabetes and cardiovascular disease risk factors. METHODS: A randomized 6-month delayed control design was utilized, with two thirds of the participants assigned to begin intervention immediately, and one third beginning 6 months later. The year-long program (weekly for 3 months transitioning to monthly) focused on weight loss and increasing physical activity. RESULTS: The immediate intervention group had greater mean weight loss (-10.4 lb, 5.1%, vs -2.3 lb, 1%; P = 0.0001) than the delayed control group at 6 months and relatively greater improvements in activity, HbA1c, and other risk factors. The delayed group experienced similar improvements after completing the intervention program. CONCLUSIONS: A worksite behavioral lifestyle intervention is feasible and effective in significantly improving risk factors for type 2 diabetes and cardiovascular disease.

Patient, physician, and consumer drivers: referrals for short stature and access to specialty drugs.

BACKGROUND: Candidates for specialty drugs, the fastest growing and costliest pharmaceuticals, typically originate with primary care referrals. However, little is known about what drives such referrals-especially for large populations such as short, otherwise normal children (idiopathic short stature). Recent expanded approval of growth hormone (GH) makes more than 585,000 US children eligible for such treatment, potentially costing over $11 billion/y. METHODS: To quantify the relative impact of patient physiological indicators, physician characteristics, and consumer preferences on referrals to endocrinologists (and potential access to GH) for short children, a national study of 1268 randomly selected US pediatricians was conducted, based on a full factorial experimental design in a structured survey. RESULTS: While patient indicators (height, growth pattern) influenced referrals (P < 0.001), consumer drivers (family concern) and physician attitudes had almost as great an impact-especially for children with less severe growth impairment (P < 0.001). Physician belief that short stature impairs emotional well-being and physician characteristics (female, older, shorter, beliefs about drug company information) increased referrals (P < 0.03-0.001)-independent of growth parameters. CONCLUSIONS: Referral recommendations that create the pool of candidates for the specialty drug GH are heavily swayed by physician characteristics and consumer preferences, particularly in the absence of compelling physiological evidence. This makes most of children with short stature strikingly susceptible to nonphysiological influences on referrals that render them candidates for this specialty drug. Only 1 additional referral per US pediatrician would likely increase GH costs by over $100 million/y.