Soni, Hiral

Abstract Objectives We characterize physician workflow in two distinctive emergency departments (ED). Physician practices mediated by electronic health records (EHR) are explored within the context of organizational complexity for the delivery of care. Methods Two urban clinical sites, including an academic teaching ED, were selected. Fourteen physicians were recruited. Overall, 62 hours of direct clinical observations were conducted characterizing clinical activities (EHR use, team communication, and patient care). Data were analyzed using qualitative open-coding techniques and descriptive statistics. Timeline belts were used to represent temporal events. Results At site 1, physicians, engaged in more team communication, followed by direct patient care. Although physicians spent 61% of their clinical time at workstations, only 25% was spent on the EHR, primarily for clinical documentation and review. Site 2 physicians engaged primarily in direct patient care spending 52% of their time at a workstation, and 31% dedicated to EHRs, focused on chart review. At site 1, physicians showed nonlinear complex workflow patterns with a greater frequency of multitasking and interruptions, resulting in workflow fragmentation. In comparison, at site 2, a less complex environment with a unique patient assignment system, resulting in a more linear workflow pattern. Conclusion The nature of the clinical practice and EHR-mediated workflow reflects the ED work practices. Physicians in more complex organizations may be less efficient because of the fragmented workflow. However, these effects can be mitigated by effort distribution through team communication, which affords inherent safety checks.

Objective Over the last decade, electronic health records (EHRs) have shaped clinical practice. In this article, we investigated the perceived effects of EHR use on clinical workflow and meaningful use (MU) performance metrics. Materials and Methods Semistructured interviews were conducted with 20 (n = 20) physicians at two urban emergency departments. Interview questions focused on time spent on EHR use, changes in clinical practices with EHR use, and the effect of MU performance metrics on clinical workflow. Qualitative coding using grounded theory and descriptive analyses were performed to provide descriptive insights. Results Physicians reported that EHRs improved their clinical workflow, especially on MU-related activities including door-to-doctor time and admit decision time. EHR use also affected physicians work efficiency, quality of care provided, and overall patient safety. Conclusion Physicians' perception of EHRs is likely to influence their practices. With negative perceptions of EHR usability problems, positive aspects of EHR use, including the influence on MU performance metrics, may be overridden.

Background Type 1 diabetes (T1D) care requires multiple daily self-management behaviors (SMBs). Preliminary studies on SMBs rely mainly on self-reported survey and interview data. There is little information on adult T1D SMBs, along with corresponding compensation techniques (CTs), gathered in real-time. Objective The article aims to use a patient-centered approach to design iDECIDE, a smartphone application that gathers daily diabetes SMBs and CTs related to meal and alcohol intake and exercise in real-time, and contrast patients' actual behaviors against those self-reported with the app. Methods Two usability studies were used to improve iDECIDE's functionality. These were followed by a 30-day pilot test of the redesigned app. A survey designed to capture diabetes SMBs and CTs was administered prior to the 30-day pilot test. Survey results were compared against iDECIDE logs. Results Usability studies revealed that participants desired advanced features for self-tracking meals and alcohol intake. Thirteen participants recorded over 1,200 CTs for carbohydrates during the 30-day study. Participants also recorded 76 alcohol and 166 exercise CTs. Comparisons of survey responses and iDECIDE logs showed mean% (standard deviation) concordance of 77% (25) for SMBs related to meals, where concordance of 100% indicates a perfect match. There was low concordance of 35% (35) and 46% (41) for alcohol and exercise events, respectively. Conclusion The high variability found in SMBs and CTs highlights the need for real-time diabetes self-tracking mechanisms to better understand SMBs and CTs. Future work will use the developed app to collect SMBs and CTs and identify patient-specific diabetes adherence barriers that could be addressed with individualized education interventions.

Studies have found variability in self-care behaviors in patients with type 1 diabetes, particularly when incorporating exercise and alcohol consumption. The objective of this study was to provide results from a survey to understand (1) insulin pump behaviors, (2) reported self-management behaviors for exercise and alcohol, and (3) perceptions of the effects of exercise and alcohol on blood glucose (BG) control. Fourteen participants from an outpatient endocrinology practice were recruited and administered an electronic survey. Compensation techniques for exercise and alcohol, along with reasons for employing the techniques were identified. Also identified were factors that participants said affected BG control with regard to exercise and alcohol. These results confirm the considerable inconsistency patients have about incorporating exercise and alcohol into decisions about self-management behaviors.

Background: We propose a methodology to analyze complex real-life glucose data in insulin pump users. Methods: Patients with type 1 diabetes (T1D) on insulin pumps were recruited from an academic endocrinology practice. Glucose data, insulin bolus (IB) amounts, and self-reported alcohol consumption and exercise events were collected for 30 days. Rules were developed to retrospectively compare IB recommendations from the insulin pump bolus calculator (IPBC) against recommendations from a proposed decision aid (PDA) and for assessing the PDA’s recommendation for exercise and alcohol. Results: Data from 15 participants were analyzed. When considering instances where glucose was below target, the PDA recommended a smaller dose in 14%, but a larger dose in 13% and an equivalent IB in 73%. For glucose levels at target, the PDA suggested an equivalent IB in 58% compared to the subject’s IPBC, but higher doses in 20% and lower in 22%. In events where postprandial glucose was higher than target, the PDA suggested higher doses in 25%, lower doses in 13%, and equivalent doses in 62%. In 64% of all alcohol events the PDA would have provided appropriate advice. In 75% of exercise events, the PDA appropriately advised an IB, a carbohydrate snack, or neither. Conclusions: This study provides a methodology to systematically analyze real-life data generated by insulin pumps and allowed a preliminary analysis of the performance of the PDA for insulin dosing. Further testing of the methodological approach in a broader diabetes population and prospective testing of the PDA are needed.

Background: There is a lack of systematic ways to analyze how diabetes patients use their insulin pumps to self-manage blood glucose to compensate for alcohol ingestion and exercise. The objective was to analyze “real-life” insulin dosing decisions occurring in conjunction with alcohol intake and exercise among patients using insulin pumps. Methods: We recruited adult type 1 diabetes (T1D) patients on insulin pump therapy. Participants were asked to maintain their daily routines, including those related to exercising and consuming alcohol, and keep a 30-day journal on exercise performed and alcohol consumed. Thirty days of insulin pump data were downloaded. Participants’ actual insulin dosing behaviors were compared against their self-reported behaviors in the setting of exercise and alcohol. Results: Nineteen T1D patients were recruited and over 4000 interactions with the insulin pump were analyzed. The analysis exposed variability in how subjects perceived the effects of exercise/alcohol on their blood glucose, inconsistencies between self-reported and observed behaviors, and higher rates of blood glucose control behaviors for exercise versus alcohol. Conclusion: Compensation techniques and perceptions on how exercise and alcohol affect their blood glucose levels vary between patients. Improved individualized educational techniques that take into consideration a patient’s unique life style are needed to help patients effectively apply alcohol and exercise compensation techniques.

Background: Successful diabetes management requires behavioral changes. Little is known about self-management behaviors (SMB) in adults on insulin pump (IP) therapy. Objective: Analyze and characterize observed common diabetes SMB in adult participants with type 1 diabetes (T1D) using IPs and to correlate behaviors with glycemic outcomes based on participant’s individual glucose targets. Materials and Methods: One month of IP data from adults with T1D were downloaded. Computer programs were written to automatically quantify the observed frequency of expected behaviors such as: insulin bolusing, checking blood glucose (BG), and recording carbohydrate intake, and other interactions with the IP. Results: Nineteen participants were recruited and 4,249 IP interactions were analyzed to ascertain behaviors. Intersubject variability of adherence to minimally expected behaviors was observed: daily documentation of carbohydrates and BG checks in 76.6 (31.7)% and 60.0 (32.5)%, respectively, and bolusing without consulting the IPBC in 13.0 (16.9)% of delivered boluses, while daily insulin bolus delivery was consistent 96.8 (5.7)%. Higher frequency of adherence to daily behaviors correlated with a higher number of glucose readings at target. Conclusion: Results indicate variability in SMB and do not always match recommendations. Case-scenarios based on observed real-life SMB could be incorporated into interviews/surveys to elucidate ways to improve SMB.