Patient engagement in the inpatient setting: a systematic review

Objective

To systematically review existing literature regarding patient engagement technologies used in the inpatient setting.

Methods

PubMed, Association for Computing Machinery (ACM) Digital Library, Institute of Electrical and Electronics Engineers (IEEE) Xplore, and Cochrane databases were searched for studies that discussed patient engagement (‘self-efficacy’, ‘patient empowerment’, ‘patient activation’, or ‘patient engagement’), (2) involved health information technology (‘technology’, ‘games’, ‘electronic health record’, ‘electronic medical record’, or ‘personal health record’), and (3) took place in the inpatient setting (‘inpatient’ or ‘hospital’). Only English language studies were reviewed.

Results

17 articles were identified describing the topic of inpatient patient engagement. A few articles identified design requirements for inpatient engagement technology. The remainder described interventions, which we grouped into five categories: entertainment, generic health information delivery, patient-specific information delivery, advanced communication tools, and personalized decision support.

Conclusions

Examination of the current literature shows there are considerable gaps in knowledge regarding patient engagement in the hospital setting and inconsistent use of terminology regarding patient engagement overall. Research on inpatient engagement technologies has been limited, especially concerning the impact on health outcomes and cost-effectiveness.     

Resolution pattern of jaundice among children presenting with severe malaria in rural South-West Nigeria

Objective

To compare the pattern of jaundice resolution among children with severe malaria treated with quinine and artemether.

Methods

Thirty two children who fulfilled the inclusion criteria were recruited for the study from two hospitals with intensive care facilities. They were divided into two groups; ‘Q’ and ‘A’, receiving quinine and artemether, respectively. Jaundice was assessed by clinical examination.

Results

Sixteen out of 32 children recruited (representing 50%) presented with jaundice on the day of recruitment. The mean age was (7.00°C2.56) years. On day 3, four patients in ‘A’ and six patients in ‘Q’ had jaundice. By day 7, no child had jaundice.

Conclusion

The study has shown that both drugs resolve jaundice although artemether relatively resolves it faster by the third day.     

Using statistical text classification to identify health information technology incidents

Objective

To examine the feasibility of using statistical text classification to automatically identify health information technology (HIT) incidents in the USA Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database.

Design

We used a subset of 570 272 incidents including 1534 HIT incidents reported to MAUDE between 1 January 2008 and 1 July 2010. Text classifiers using regularized logistic regression were evaluated with both ‘balanced’ (50% HIT) and ‘stratified’ (0.297% HIT) datasets for training, validation, and testing. Dataset preparation, feature extraction, feature selection, cross-validation, classification, performance evaluation, and error analysis were performed iteratively to further improve the classifiers. Feature-selection techniques such as removing short words and stop words, stemming, lemmatization, and principal component analysis were examined.

Measurements

κ statistic, F1 score, precision and recall.

Results

Classification performance was similar on both the stratified (0.954 F1 score) and balanced (0.995 F1 score) datasets. Stemming was the most effective technique, reducing the feature set size to 79% while maintaining comparable performance. Training with balanced datasets improved recall (0.989) but reduced precision (0.165).

Conclusions

Statistical text classification appears to be a feasible method for identifying HIT reports within large databases of incidents. Automated identification should enable more HIT problems to be detected, analyzed, and addressed in a timely manner. Semi-supervised learning may be necessary when applying machine learning to big data analysis of patient safety incidents and requires further investigation.     

Awake Craniotomy for Tumour Excision

Background

Craniotomy and excision of tumours can produce neurological deficits if the tumour is located close to eloquent areas of the brain. One technique of overcoming this problem is to keep the patient ‘awake’ during surgery.

Methods

Eight patients with intra cranial space occupying lesions (ICSOL) were operated ‘awake’, using a combination of skull block with sedation and analgesia. A mixture of 0.125% bupivacaine and 0.5% lignocaine was used for various nerve and field blocks. Midazolam, fentanyl and propofol in titrated doses were used to achieve conscious sedation.

Result

The procedure was successful in all the patients. They tolerated the procedure well and were able to follow the commands intraoperatively as desired. There were no significant complications.

Conclusion

Awake craniotomy with skull blocks with sedation and analgesia is a well established procedure. It requires a good rapport between surgeon, anaesthesiologist and the patient.Key Words: Awake craniotomy, Skull block, Sedation, Analgesia     

Psychological Well-being of Medical Students

Background

Training in medicine is emotionally demanding. Psychological well being of medical students is a matter of concern. There is lack of Indian studies in this area.

Methods

A total of 105 medical student of one batch were assessed utilizing psychophysiological state inventory, Institute for personality and ability testing (IPAT) anxiety and depression scale, achievement motivation scale, scale for locus of control and 16 PF in three phases at one-year intervals.

Result

Majority of the students had average achievement, motivation and adaptability. Anxiety and depression scores fell within normal limits. In personality profile factor ‘B’, ‘M’ and ‘Q4₁’ had changed significantly. Achievement motivation showed significant decreases and CSS1 and PO1 scores showed significant increase during the years of medical education.

Conclusion

The results demonstrate that over satisfaction and relaxed attitude may have poor academic outcome.Key Words: Psychological well-being, Anxiety, Depression, Achievement motivation     

An analysis of electronic health record-related patient safety concerns

Objective

A recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system.

Methods

The Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports.

Results

We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or ‘hidden dependencies’ within the EHR.

Discussion

EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after ‘go-live’ and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA.

Conclusions

Because EHR-related safety concerns have complex sociotechnical origins, institutions with long-standing as well as recent EHR implementations should build a robust infrastructure to monitor and learn from them.     

Research and applications: ICD-9 tobacco use codes are effective identifiers of smoking status

Objective

To evaluate the validity of, characterize the usage of, and propose potential research applications for International Classification of Diseases, Ninth Revision (ICD-9) tobacco codes in clinical populations.

Materials and methods

Using data on cancer cases and cancer-free controls from Vanderbilt''s biorepository, BioVU, we evaluated the utility of ICD-9 tobacco use codes to identify ever-smokers in general and high smoking prevalence (lung cancer) clinic populations. We assessed potential biases in documentation, and performed temporal analysis relating transitions between smoking codes to smoking cessation attempts. We also examined the suitability of these codes for use in genetic association analyses.

Results

ICD-9 tobacco use codes can identify smokers in a general clinic population (specificity of 1, sensitivity of  0.32), and there is little evidence of documentation bias. Frequency of code transitions between ‘current’ and ‘former’ tobacco use was significantly correlated with initial success at smoking cessation (p<0.0001). Finally, code-based smoking status assignment is a comparable covariate to text-based smoking status for genetic association studies.

Discussion

Our results support the use of ICD-9 tobacco use codes for identifying smokers in a clinical population. Furthermore, with some limitations, these codes are suitable for adjustment of smoking status in genetic studies utilizing electronic health records.

Conclusions

Researchers should not be deterred by the unavailability of full-text records to determine smoking status if they have ICD-9 code histories.     

MITRE system for clinical assertion status classification

Objective

To describe a system for determining the assertion status of medical problems mentioned in clinical reports, which was entered in the 2010 i2b2/VA community evaluation ‘Challenges in natural language processing for clinical data’ for the task of classifying assertions associated with problem concepts extracted from patient records.

Materials and methods

A combination of machine learning (conditional random field and maximum entropy) and rule-based (pattern matching) techniques was used to detect negation, speculation, and hypothetical and conditional information, as well as information associated with persons other than the patient.

Results

The best submission obtained an overall micro-averaged F-score of 0.9343.

Conclusions

Using semantic attributes of concepts and information about document structure as features for statistical classification of assertions is a good way to leverage rule-based and statistical techniques. In this task, the choice of features may be more important than the choice of classifier algorithm.     

Efficacy of Deltamethrin and Cyfluthrin Impregnated Cloth over Uniform against Mosquito Bites

Background

The difficulty with insecticide treated mosquito nets is that in military operation, it may not be practical for the personnel to carry mosquito nets with them. In mobile military operations, availability of pre-treated ‘patches of cloth’ or ‘bands’, which can be applied over the uniform at strategic sites, could be a feasible alternative.

Methods

A double blind randomised controlled trial was undertaken among troops deployed in counter-insurgency operations in the northeastern parts of the country, to assess the efficacy of synthetic pyrethroid pretreated patches in reducing man mosquito contact, as compared to conventional repellents.

Result

The study indicated that pretreated patches, when affixed over the uniform, provided significantly higher protection from mosquito bites, when used in addition to the conventional repellents.

Conclusion

The study recommends that synthetic pyrethroid treated patches be made available to troops operating in highly malarious areas.Key Words: Synthetic pyrethroid treated patches, Man-mosquito contact     

Research and applications: Role of genetic heterogeneity and epistasis in bladder cancer susceptibility and outcome: a learning classifier system approach

Background and objective

Detecting complex patterns of association between genetic or environmental risk factors and disease risk has become an important target for epidemiological research. In particular, strategies that provide multifactor interactions or heterogeneous patterns of association can offer new insights into association studies for which traditional analytic tools have had limited success.

Materials and methods

To concurrently examine these phenomena, previous work has successfully considered the application of learning classifier systems (LCSs), a flexible class of evolutionary algorithms that distributes learned associations over a population of rules. Subsequent work dealt with the inherent problems of knowledge discovery and interpretation within these algorithms, allowing for the characterization of heterogeneous patterns of association. Whereas these previous advancements were evaluated using complex simulation studies, this study applied these collective works to a ‘real-world’ genetic epidemiology study of bladder cancer susceptibility.

Results and discussion

We replicated the identification of previously characterized factors that modify bladder cancer risk—namely, single nucleotide polymorphisms from a DNA repair gene, and smoking. Furthermore, we identified potentially heterogeneous groups of subjects characterized by distinct patterns of association. Cox proportional hazard models comparing clinical outcome variables between the cases of the two largest groups yielded a significant, meaningful difference in survival time in years (survivorship). A marginally significant difference in recurrence time was also noted. These results support the hypothesis that an LCS approach can offer greater insight into complex patterns of association.

Conclusions

This methodology appears to be well suited to the dissection of disease heterogeneity, a key component in the advancement of personalized medicine.     

Research and applications: The discriminatory cost of ICD-10-CM transition between clinical specialties: metrics,case study,and mitigating tools

Objective

Applying the science of networks to quantify the discriminatory impact of the ICD-9-CM to ICD-10-CM transition between clinical specialties.

Materials and Methods

Datasets were the Center for Medicaid and Medicare Services ICD-9-CM to ICD-10-CM mapping files, general equivalence mappings, and statewide Medicaid emergency department billing. Diagnoses were represented as nodes and their mappings as directional relationships. The complex network was synthesized as an aggregate of simpler motifs and tabulation per clinical specialty.

Results

We identified five mapping motif categories: identity, class-to-subclass, subclass-to-class, convoluted, and no mapping. Convoluted mappings indicate that multiple ICD-9-CM and ICD-10-CM codes share complex, entangled, and non-reciprocal mappings. The proportions of convoluted diagnoses mappings (36% overall) range from 5% (hematology) to 60% (obstetrics and injuries). In a case study of 24 008 patient visits in 217 emergency departments, 27% of the costs are associated with convoluted diagnoses, with ‘abdominal pain’ and ‘gastroenteritis’ accounting for approximately 3.5%.

Discussion

Previous qualitative studies report that administrators and clinicians are likely to be challenged in understanding and managing their practice because of the ICD-10-CM transition. We substantiate the complexity of this transition with a thorough quantitative summary per clinical specialty, a case study, and the tools to apply this methodology easily to any clinical practice in the form of a web portal and analytic tables.

Conclusions

Post-transition, successful management of frequent diseases with convoluted mapping network patterns is critical. The http://lussierlab.org/transition-to-ICD10CM web portal provides insight in linking onerous diseases to the ICD-10 transition.     

Longitudinal analysis of pain in patients with metastatic prostate cancer using natural language processing of medical record text

Objectives

To test the feasibility of using text mining to depict meaningfully the experience of pain in patients with metastatic prostate cancer, to identify novel pain phenotypes, and to propose methods for longitudinal visualization of pain status.

Materials and methods

Text from 4409 clinical encounters for 33 men enrolled in a 15-year longitudinal clinical/molecular autopsy study of metastatic prostate cancer (Project to ELIminate lethal CANcer) was subjected to natural language processing (NLP) using Unified Medical Language System-based terms. A four-tiered pain scale was developed, and logistic regression analysis identified factors that correlated with experience of severe pain during each month.

Results

NLP identified 6387 pain and 13 827 drug mentions in the text. Graphical displays revealed the pain ‘landscape’ described in the textual records and confirmed dramatically increasing levels of pain in the last years of life in all but two patients, all of whom died from metastatic cancer. Severe pain was associated with receipt of opioids (OR=6.6, p<0.0001) and palliative radiation (OR=3.4, p=0.0002). Surprisingly, no severe or controlled pain was detected in two of 33 subjects’ clinical records. Additionally, the NLP algorithm proved generalizable in an evaluation using a separate data source (889 Informatics for Integrating Biology and the Bedside (i2b2) discharge summaries).

Discussion

Patterns in the pain experience, undetectable without the use of NLP to mine the longitudinal clinical record, were consistent with clinical expectations, suggesting that meaningful NLP-based pain status monitoring is feasible. Findings in this initial cohort suggest that ‘outlier’ pain phenotypes useful for probing the molecular basis of cancer pain may exist.

Limitations

The results are limited by a small cohort size and use of proprietary NLP software.

Conclusions

We have established the feasibility of tracking longitudinal patterns of pain by text mining of free text clinical records. These methods may be useful for monitoring pain management and identifying novel cancer phenotypes.     

Social determinants of stunting in rural area of Wardha,Central India

Background

Stunting is a consequence of long term, cumulative inadequacies of health and nutrition. Health system uses underweight for growth monitoring for its simplicity. Lately there is renewed interest in stunting and especially severe acute malnutrition. Stunting is a relatively neglected indicator. It is therefore imperative to understand the causes of stunting early in infancy and childhood, so that preventive measures can be taken. Hence, the present study was undertaken to study the social determinants of stunting in rural Wardha.

Methods

The present cross-sectional study was undertaken in three Primary Health Centres (PHCs) of Wardha district with total population of 88,187. The sample was drawn from three PHC areas by 30-cluster sampling technique. Stunting was defined using WHO Child Growth Standards for ‘height-for-age’. ‘Height-for-age’ values below 2 standard deviations were considered as stunted while below 3 standard deviations were considered ‘severe stunting’.

Result

Prevalence of stunting was observed to be 52.3% and severe stunting was 25.1%. The significant determinants of stunting were found to be age, father''s education, fathers'' occupation, low income, not receiving Vitamin-A supplement during last 6 months and having anaemia. Sex, caste, mother''s education and mothers'' occupation did not contribute significantly to the stunting.

Conclusion

Low income and related factors such as father''s education and his occupation are important determinant of the stunting. Father being the decision maker, his education is of importance. Vitamin-A supplementation and anaemia as surrogate indicators for access to health care also found out to be significant determinants of stunting.     

Assessing the quality,suitability and readability of internet-based health information about warfarin for patients

Background

Warfarin is a high-risk medication where patient information may be critical to help ensure safe and effective treatment. Considering the time constraints of healthcare providers, the internet can be an important supplementary information resource for patients prescribed warfarin. The usefulness of internet-based patient information is often limited by challenges associated with finding valid and reliable health information. Given patients'' increasing access of the internet for information, this study investigated the quality, suitability and readability of patient information about warfarin presented on the internet.

Method

Previously validated tools were used to evaluate the quality, suitability and readability of patient information about warfarin on selected websites.

Results

The initial search yielded 200 websites, of which 11 fit selection criteria, comprising seven non-commercial and four commercial websites. Regarding quality, most of the non-commercial sites (six out of seven) scored at least an ‘adequate’ score. With regard to suitability, 6 of the 11 websites (including two of the four commercial sites) attained an ‘adequate’ score. It was determined that information on 7 of the 11 sites (including two commercial sites) was written at reading grade levels beyond that considered representative of the adult patient population with poor literacy skills (e.g. school grade 8 or less).

Conclusion

Despite the overall ‘adequate’ quality and suitability of the internet derived patient information about warfarin, the actual usability of such websites may be limited due to their poor readability grades, particularly in patients with low literacy skills.     

Mediation of adoption and use: a key strategy for mitigating unintended consequences of health IT implementation

Objective

Without careful attention to the work of users, implementation of health IT can produce new risks and inefficiencies in care. This paper uses the technology use mediation framework to examine the work of a group of nurses who serve as mediators of the adoption and use of a barcode medication administration (BCMA) system in an inpatient setting.

Materials and methods

The study uses ethnographic methods to explore the mediators'' work. Data included field notes from observations, documents, and email communications. This variety of sources enabled triangulation of findings between activities observed, discussed in meetings, and reported in emails.

Results

Mediation work integrated the BCMA tool with nursing practice, anticipating and solving implementation problems. Three themes of mediation work include: resolving challenges related to coordination, integrating the physical aspects of BCMA into everyday practice, and advocacy work.

Discussion

Previous work suggests the following factors impact mediation effectiveness: proximity to the context of use, understanding of users'' practices and norms, credibility with users, and knowledge of the technology and users'' technical abilities. We describe three additional factors observed in this case: ‘influence on system developers,’ ‘influence on institutional authorities,’ and ‘understanding the network of organizational relationships that shape the users'' work.’

Conclusion

Institutionally supported clinicians who facilitate adoption and use of health IT systems can improve the safety and effectiveness of implementation through the management of unintended consequences. Additional research on technology use mediation can advance the science of implementation by providing decision-makers with theoretically durable, empirically grounded evidence for designing implementations.     

Psychosocial Variables of Voluntary Blood Donors at Blood Bank of a Medical College

Background

This study was undertaken to study the motivational factors leading to voluntary blood donation and understanding the psychosocial variables of blood donors.

Methods

300 blood donors were selected by systematic random sampling method.

Result

It was observed that most of the voluntary donors were males (89.3%) and belonged to age group 16-25 years (48%). Most of the donors (93.46%) had studied upto high school and above and 84.33% of the donors belonged to the middle class. 27% of the donors had donated blood previously. The common motivational factors to donate blood were for ‘a good cause'', ‘for the society’ and ‘to save a life''. 4.67% of them donated blood for self satisfaction.

Conclusion

Motivation, recruitment and retention of voluntary blood donors are important criteria to achieve safe blood donation.Key Words: Motivation, Psychosocial, Voluntary, Blood Donors     

Failure to utilize functions of an electronic prescribing system and the subsequent generation of ‘technically preventable’ computerized alerts

Objectives

To determine the frequency with which computerized alerts occur and the proportion triggered as a result of prescribers not utilizing e-prescribing system functions.

Methods

An audit of electronic inpatient medication charts at a teaching hospital in Sydney, Australia, was conducted to identify alerts fired, to categorize the system functions used by prescribers, and to assess if use of short-cut system functions could have prevented the alerts.

Results

Of the 2209 active orders reviewed, 600 (27.2%) triggered at least one alert. Therapeutic duplication alerts were the most frequent (n=572). One third of these (20.2% of all alerts) was ‘technically preventable’ and would not have fired if prescribers had used a short-cut system function to prescribe. Under-utilized system functions included the option to ‘MODIFY’ existing orders and use of the ‘AND’ function for concurrent orders. Pregnancy alerts, set for women aged between 12 and 55 years, were triggered for 43% of drugs ordered for this group.

Conclusion

Developers of decision support systems should test the extent to which technically preventable alerts may arise when prescribers fail to use system functions as designed. Designs which aim to improve the efficiency of the prescribing process but which do not align with the cognitive processes of users may fail to achieve this desired outcome and produce unexpected consequences such as triggering unnecessary alerts and user frustration. Ongoing user training to support effective use of e-prescribing system functions and modifications to the mechanisms underlying alert generation are needed to ensure that prescribers are presented with fewer but more meaningful alerts.     

Differentials and Determinants of Syndrome ‘X’ and its Role as Coronary Risk among Healthy Middle Aged Indian Army Personnel

Background

Syndrome ‘X’, a clustering of impaired glucose tolerance (IGT), raised blood pressure, raised serum triglycerides and low HDL-cholesterol, occurring under the influence of insulin resistance and resultant hyperinsulinaemia, has been hypothesised to be a major risk factor for ischaemic heart disease (IHD). However, there is a lack of research based evidence in this field, in our country.

Methods

The study was a cross-sectional analytical epidemiological design of 614 healthy Indian Army personnel, aged 35 years and above, selected by random sampling.

Results

The study indicated that there is a statistically significant (p < 0.001) clustering between fasting hyperinsulinaemia, raised blood pressure, IGT, raised triglycerides and low HDL. The prevalence of syndrome ‘X’ was 8.47% (95% CI 6.27% to 10.47%). Initial univariate and subsequent multivariate analysis using multiple logistic regression method, indicated that predictors of syndrome ‘X’ were increasing age, overweight, increasing central (abdominal) obesity, lack of adequate physical exercise and low level of physical fitness. Presence of syndrome ‘X’ increased the risk of resting ECG changes suggestive of coronary insufficiency (OR = 6.29, p < 0.001).

Conclusion

Based on the findings, recommendations for prevention of this syndrome have been submitted.Key Words: Syndrome ‘X’, Insulin resistance syndrome, Ischaemic heart disease, Coronary Risk factors, Military personnel