Objective: Build and validate a clinical decision support (CDS) algorithm for discharge decisions... more Objective: Build and validate a clinical decision support (CDS) algorithm for discharge decisions regarding referral for post-acute care (PAC) and to what site of care. Materials and Methods: Case studies derived from EHR data were judged by 171 interdisciplinary experts and prediction models were generated. Results: A two-step algorithm emerged with area under the curve (AUC) in validation of 91.5% (yes/no refer) and AUC 89.7% (where to refer). Discussion: CDS for discharge planning (DP) decisions may remove subjectivity, and variation in decision-making. CDS could automate the assessment process and alert clinicians of high need patients earlier in the hospital stay. Conclusion: Our team successfully built and validated a two-step algorithm to support discharge referral decision-making from EHR data. Getting patients the care and support they need may decrease readmissions and other adverse events. Further work is underway to test the effects of the CDS on patient outcomes in two ...
Sepsis survivors transitioning from hospital-to-home are clinically complex. Family caregivers ca... more Sepsis survivors transitioning from hospital-to-home are clinically complex. Family caregivers can face challenges managing patients’ care needs; however, skilled home health care (HHC) can serve as an important resource during this care transition. This study’s purpose was to describe caregiving needs among older sepsis survivors receiving post-acute HHC, and identify sources of unmet caregiving needs. We conducted a retrospective analysis of a national dataset of Medicare beneficiaries starting a new HHC episode who were after hospital discharge for sepsis between 2013 and 2014 (n=165,228). All patients received at least one HHC visit the first week after hospital discharge. Caregiving activities included seven items from the start of care Outcome and Assessment Information Set. Descriptive statistics were used to examine types of caregiving activities and needs, demographics, and clinical information. Proportions of patients with unmet caregiving needs ranged from 9%-29%, with th...
Background Despite evidence suggesting higher quality and safer care in hospitals with comprehens... more Background Despite evidence suggesting higher quality and safer care in hospitals with comprehensive electronic health record (EHR) systems, factors related to advanced system usability remain largely unknown, particularly among nurses. Little empirical research has examined sociotechnical factors, such as the work environment, that may shape the relationship between advanced EHR adoption and quality of care. Objective The objective of this study was to examine the independent and joint effects of comprehensive EHR adoption and the hospital work environment on nurse reports of EHR usability and nurse-reported quality of care and safety. Methods This study was a secondary analysis of nurse and hospital survey data. Unadjusted and adjusted logistic regression models were used to assess the relationship between EHR adoption level, work environment, and a set of EHR usability and quality/safety outcomes. The sample included 12,377 nurses working in 353 hospitals. Results In fully adjust...
The Early Screen for Discharge Planning (ESDP) is a decision support tool developed in an urban a... more The Early Screen for Discharge Planning (ESDP) is a decision support tool developed in an urban academic medical center. High ESDP scores identify patients with nonroutine discharge plans who would benefit from early discharge planning intervention. We aimed to determine the predictive performance of the ESDP in a different practice setting. Rural regional community hospital. We designed a comparative, descriptive survey study and enrolled a convenience sample of 222 patients (identified at admission) who provided informed consent. Sample characteristics and ESDP scores were collected during enrollment. The Problems After Discharge Questionnaire, EuroQoL-5Dimensions quality-of-life measure, length of stay, and use of post-acute care services were recorded after discharge. We compared outcomes between patients with low and high ESDP scores. More than half of the sample (51.8%) had a high ESDP score. Patients with high ESDP scores reported more problems after discharge (p = .02), repo...
The purpose of the current study was to explore what hospitalized patients would like to know abo... more The purpose of the current study was to explore what hospitalized patients would like to know about post-acute care (PAC) services to ultimately help them make an informed decision when offered PAC options. Thirty hospitalized adults 55 and older in a Northeastern U.S. academic medical center participated in a qualitative descriptive study with conventional content analysis as the analytical technique. Three themes emerged: (a) r eceiving practical information about the services , (b) understanding “how it relates to me,” and (c) having opportunities to understand PAC options . Study findings inform clinicians what information should be included when discussing PAC options with older adults. Improving the quality of discharge planning discussions may better inform patient decision making and, as a result, increase the numbers of patients who accept a plan of care that supports recovery, meets their needs, and results in improved quality of life and fewer readmissions. [Res Gerontol ...
Telehealth data overload through high alert generation is a significant barrier to sustained adop... more Telehealth data overload through high alert generation is a significant barrier to sustained adoption of telehealth for managing HF patients. To explore the factors contributing to frequent telehealth alerts including false alerts for Medicare heart failure (HF) patients admitted to a home health agency. A mixed methods design that combined quantitative correlation analysis of patient characteristic data with number of telehealth alerts and qualitative analysis of telehealth and visiting nurses' notes on follow-up actions to patients' telehealth alerts was employed. All the quantitative and qualitative data was collected through retrospective review of electronic records of the home heath agency. Subjects in the study had a mean age of 83 (SD = 7.6); 56% were female. Patient co-morbidities (p<0.05) of renal disorders, anxiety, and cardiac arrhythmias emerged as predictors of telehealth alerts through quantitative analysis (n = 168) using multiple regression. Inappropriate...
Sepsis survivors have the second highest readmission rate among Medicare beneficiaries, next to h... more Sepsis survivors have the second highest readmission rate among Medicare beneficiaries, next to heart failure. I-TRANSFER is an implementation science study to improve transitions and reduce readmissions among sepsis survivors transitioning from acute to home health care (HHC). A total of 63 semi-structured interviews were conducted with stakeholders among 12 hospitals and 5 affiliated home health agencies (HHAs). The purpose of this secondary analysis was to: 1) examine how the sepsis diagnosis is reflected in HHC documentation, 2) identify barriers in sepsis information transfer to HHC, 3) recommend a documentation strategy to enhance information transfer and HHC documentation. We analyzed the diagnosis coding within a national OASIS dataset and eight I-TRANSFER interviews with hospitalists, documentation specialists, and HHC coders. Findings include: a) sepsis diagnoses were nearly invisible in HHC records being documented for only 10% of 165,000 sepsis survivors transitioned to ...
International journal of nursing studies, Jan 19, 2016
Electronic health records are being increasingly used by nurses with up to 80% of the health data... more Electronic health records are being increasingly used by nurses with up to 80% of the health data recorded as free text. However, only a few studies have developed nursing-relevant tools that help busy clinicians to identify information they need at the point of care. This study developed and validated one of the first automated natural language processing applications to extract wound information (wound type, pressure ulcer stage, wound size, anatomic location, and wound treatment) from free text clinical notes. First, two human annotators manually reviewed a purposeful training sample (n=360) and random test sample (n=1100) of clinical notes (including 50% discharge summaries and 50% outpatient notes), identified wound cases, and created a gold standard dataset. We then trained and tested our natural language processing system (known as MTERMS) to process the wound information. Finally, we assessed our automated approach by comparing system-generated findings against the gold stan...
Studies in health technology and informatics, 2006
The Omaha System is a classification system or standardized terminology designed to enhance pract... more The Omaha System is a classification system or standardized terminology designed to enhance practice, documentation, and information management. Fifty unique studies were identified that focused on the Omaha System's Problem Classification Scheme, the Intervention Scheme, and the Problem Rating Scale for Outcomes. A computerized search of the research literature used CINAHL, MEDLINE, and Dissertation Abstracts databases for the years 1982 to 2003 on the keyword, Omaha System. Nursing studies predominated and were organized into eight categories. Based on the review, recommendations were made for future Omaha System research.
Background This protocol is based on home health care (HHC) best practice evidence showing the va... more Background This protocol is based on home health care (HHC) best practice evidence showing the value of coupling timely post-acute care visits by registered nurses and early outpatient provider follow-up for sepsis survivors. We found that 30-day rehospitalization rates were 7 percentage points lower (a 41% relative reduction) when sepsis survivors received a HHC nursing visit within 2 days of hospital discharge, at least 1 more nursing visit the first week, and an outpatient provider follow-up visit within 7 days compared to those without timely follow-up. However, nationwide, only 28% of sepsis survivors who transitioned to HHC received this timely visit protocol. The opportunity exists for many more sepsis survivors to benefit from timely home care and outpatient services. This protocol aims to achieve this goal. Methods Guided by the Consolidated Framework for Implementation Research, this Type 1 hybrid pragmatic study will test the effectiveness of the Improving Transitions an...
Studies in Health Technology and Informatics, 2014
This paper will describe the process for taking a decision support solution to market as a start-... more This paper will describe the process for taking a decision support solution to market as a start-up business. The nurse inventor and Co-Founder of RightCare Solutions, Inc. will share the steps from answering a clinical question, to registering an invention, creating a business plan and company, obtaining venture funding, and launching a commercial product. We will share positives about the experience such as how to get start-up funds, gaining national exposure and access to an excellent team, disseminating your work broadly, further enhancing the product, and obtaining equity, and financial rewards. We will discuss cons such as losing control, dilution of ownership, and conflict of interest. This paper will encourage nurse informaticians to think differently and learn about the steps in the process from an experienced team.
Objective: Build and validate a clinical decision support (CDS) algorithm for discharge decisions... more Objective: Build and validate a clinical decision support (CDS) algorithm for discharge decisions regarding referral for post-acute care (PAC) and to what site of care. Materials and Methods: Case studies derived from EHR data were judged by 171 interdisciplinary experts and prediction models were generated. Results: A two-step algorithm emerged with area under the curve (AUC) in validation of 91.5% (yes/no refer) and AUC 89.7% (where to refer). Discussion: CDS for discharge planning (DP) decisions may remove subjectivity, and variation in decision-making. CDS could automate the assessment process and alert clinicians of high need patients earlier in the hospital stay. Conclusion: Our team successfully built and validated a two-step algorithm to support discharge referral decision-making from EHR data. Getting patients the care and support they need may decrease readmissions and other adverse events. Further work is underway to test the effects of the CDS on patient outcomes in two ...
Sepsis survivors transitioning from hospital-to-home are clinically complex. Family caregivers ca... more Sepsis survivors transitioning from hospital-to-home are clinically complex. Family caregivers can face challenges managing patients’ care needs; however, skilled home health care (HHC) can serve as an important resource during this care transition. This study’s purpose was to describe caregiving needs among older sepsis survivors receiving post-acute HHC, and identify sources of unmet caregiving needs. We conducted a retrospective analysis of a national dataset of Medicare beneficiaries starting a new HHC episode who were after hospital discharge for sepsis between 2013 and 2014 (n=165,228). All patients received at least one HHC visit the first week after hospital discharge. Caregiving activities included seven items from the start of care Outcome and Assessment Information Set. Descriptive statistics were used to examine types of caregiving activities and needs, demographics, and clinical information. Proportions of patients with unmet caregiving needs ranged from 9%-29%, with th...
Background Despite evidence suggesting higher quality and safer care in hospitals with comprehens... more Background Despite evidence suggesting higher quality and safer care in hospitals with comprehensive electronic health record (EHR) systems, factors related to advanced system usability remain largely unknown, particularly among nurses. Little empirical research has examined sociotechnical factors, such as the work environment, that may shape the relationship between advanced EHR adoption and quality of care. Objective The objective of this study was to examine the independent and joint effects of comprehensive EHR adoption and the hospital work environment on nurse reports of EHR usability and nurse-reported quality of care and safety. Methods This study was a secondary analysis of nurse and hospital survey data. Unadjusted and adjusted logistic regression models were used to assess the relationship between EHR adoption level, work environment, and a set of EHR usability and quality/safety outcomes. The sample included 12,377 nurses working in 353 hospitals. Results In fully adjust...
The Early Screen for Discharge Planning (ESDP) is a decision support tool developed in an urban a... more The Early Screen for Discharge Planning (ESDP) is a decision support tool developed in an urban academic medical center. High ESDP scores identify patients with nonroutine discharge plans who would benefit from early discharge planning intervention. We aimed to determine the predictive performance of the ESDP in a different practice setting. Rural regional community hospital. We designed a comparative, descriptive survey study and enrolled a convenience sample of 222 patients (identified at admission) who provided informed consent. Sample characteristics and ESDP scores were collected during enrollment. The Problems After Discharge Questionnaire, EuroQoL-5Dimensions quality-of-life measure, length of stay, and use of post-acute care services were recorded after discharge. We compared outcomes between patients with low and high ESDP scores. More than half of the sample (51.8%) had a high ESDP score. Patients with high ESDP scores reported more problems after discharge (p = .02), repo...
The purpose of the current study was to explore what hospitalized patients would like to know abo... more The purpose of the current study was to explore what hospitalized patients would like to know about post-acute care (PAC) services to ultimately help them make an informed decision when offered PAC options. Thirty hospitalized adults 55 and older in a Northeastern U.S. academic medical center participated in a qualitative descriptive study with conventional content analysis as the analytical technique. Three themes emerged: (a) r eceiving practical information about the services , (b) understanding “how it relates to me,” and (c) having opportunities to understand PAC options . Study findings inform clinicians what information should be included when discussing PAC options with older adults. Improving the quality of discharge planning discussions may better inform patient decision making and, as a result, increase the numbers of patients who accept a plan of care that supports recovery, meets their needs, and results in improved quality of life and fewer readmissions. [Res Gerontol ...
Telehealth data overload through high alert generation is a significant barrier to sustained adop... more Telehealth data overload through high alert generation is a significant barrier to sustained adoption of telehealth for managing HF patients. To explore the factors contributing to frequent telehealth alerts including false alerts for Medicare heart failure (HF) patients admitted to a home health agency. A mixed methods design that combined quantitative correlation analysis of patient characteristic data with number of telehealth alerts and qualitative analysis of telehealth and visiting nurses' notes on follow-up actions to patients' telehealth alerts was employed. All the quantitative and qualitative data was collected through retrospective review of electronic records of the home heath agency. Subjects in the study had a mean age of 83 (SD = 7.6); 56% were female. Patient co-morbidities (p<0.05) of renal disorders, anxiety, and cardiac arrhythmias emerged as predictors of telehealth alerts through quantitative analysis (n = 168) using multiple regression. Inappropriate...
Sepsis survivors have the second highest readmission rate among Medicare beneficiaries, next to h... more Sepsis survivors have the second highest readmission rate among Medicare beneficiaries, next to heart failure. I-TRANSFER is an implementation science study to improve transitions and reduce readmissions among sepsis survivors transitioning from acute to home health care (HHC). A total of 63 semi-structured interviews were conducted with stakeholders among 12 hospitals and 5 affiliated home health agencies (HHAs). The purpose of this secondary analysis was to: 1) examine how the sepsis diagnosis is reflected in HHC documentation, 2) identify barriers in sepsis information transfer to HHC, 3) recommend a documentation strategy to enhance information transfer and HHC documentation. We analyzed the diagnosis coding within a national OASIS dataset and eight I-TRANSFER interviews with hospitalists, documentation specialists, and HHC coders. Findings include: a) sepsis diagnoses were nearly invisible in HHC records being documented for only 10% of 165,000 sepsis survivors transitioned to ...
International journal of nursing studies, Jan 19, 2016
Electronic health records are being increasingly used by nurses with up to 80% of the health data... more Electronic health records are being increasingly used by nurses with up to 80% of the health data recorded as free text. However, only a few studies have developed nursing-relevant tools that help busy clinicians to identify information they need at the point of care. This study developed and validated one of the first automated natural language processing applications to extract wound information (wound type, pressure ulcer stage, wound size, anatomic location, and wound treatment) from free text clinical notes. First, two human annotators manually reviewed a purposeful training sample (n=360) and random test sample (n=1100) of clinical notes (including 50% discharge summaries and 50% outpatient notes), identified wound cases, and created a gold standard dataset. We then trained and tested our natural language processing system (known as MTERMS) to process the wound information. Finally, we assessed our automated approach by comparing system-generated findings against the gold stan...
Studies in health technology and informatics, 2006
The Omaha System is a classification system or standardized terminology designed to enhance pract... more The Omaha System is a classification system or standardized terminology designed to enhance practice, documentation, and information management. Fifty unique studies were identified that focused on the Omaha System's Problem Classification Scheme, the Intervention Scheme, and the Problem Rating Scale for Outcomes. A computerized search of the research literature used CINAHL, MEDLINE, and Dissertation Abstracts databases for the years 1982 to 2003 on the keyword, Omaha System. Nursing studies predominated and were organized into eight categories. Based on the review, recommendations were made for future Omaha System research.
Background This protocol is based on home health care (HHC) best practice evidence showing the va... more Background This protocol is based on home health care (HHC) best practice evidence showing the value of coupling timely post-acute care visits by registered nurses and early outpatient provider follow-up for sepsis survivors. We found that 30-day rehospitalization rates were 7 percentage points lower (a 41% relative reduction) when sepsis survivors received a HHC nursing visit within 2 days of hospital discharge, at least 1 more nursing visit the first week, and an outpatient provider follow-up visit within 7 days compared to those without timely follow-up. However, nationwide, only 28% of sepsis survivors who transitioned to HHC received this timely visit protocol. The opportunity exists for many more sepsis survivors to benefit from timely home care and outpatient services. This protocol aims to achieve this goal. Methods Guided by the Consolidated Framework for Implementation Research, this Type 1 hybrid pragmatic study will test the effectiveness of the Improving Transitions an...
Studies in Health Technology and Informatics, 2014
This paper will describe the process for taking a decision support solution to market as a start-... more This paper will describe the process for taking a decision support solution to market as a start-up business. The nurse inventor and Co-Founder of RightCare Solutions, Inc. will share the steps from answering a clinical question, to registering an invention, creating a business plan and company, obtaining venture funding, and launching a commercial product. We will share positives about the experience such as how to get start-up funds, gaining national exposure and access to an excellent team, disseminating your work broadly, further enhancing the product, and obtaining equity, and financial rewards. We will discuss cons such as losing control, dilution of ownership, and conflict of interest. This paper will encourage nurse informaticians to think differently and learn about the steps in the process from an experienced team.
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Papers by Kathryn Bowles