Literature DB >> 35196369

Documentation of hospitalization risk factors in electronic health records (EHRs): a qualitative study with home healthcare clinicians.

Mollie Hobensack1, Marietta Ojo2, Yolanda Barrón2, Kathryn H Bowles2,3, Kenrick Cato1,4, Sena Chae5, Erin Kennedy3, Margaret V McDonald2, Sarah Collins Rossetti1,6, Jiyoun Song1,2, Sridevi Sridharan2, Maxim Topaz1,2,7.   

Abstract

OBJECTIVE: To identify the risk factors home healthcare (HHC) clinicians associate with patient deterioration and understand how clinicians respond to and document these risk factors.
METHODS: We interviewed multidisciplinary HHC clinicians from January to March of 2021. Risk factors were mapped to standardized terminologies (eg, Omaha System). We used directed content analysis to identify risk factors for deterioration. We used inductive thematic analysis to understand HHC clinicians' response to risk factors and documentation of risk factors.
RESULTS: Fifteen HHC clinicians identified a total of 79 risk factors that were mapped to standardized terminologies. HHC clinicians most frequently responded to risk factors by communicating with the prescribing provider (86.7% of clinicians) or following up with patients and caregivers (86.7%). HHC clinicians stated that a majority of risk factors can be found in clinical notes (ie, care coordination (53.3%) or visit (46.7%)). DISCUSSION: Clinicians acknowledged that social factors play a role in deterioration risk; but these factors are infrequently studied in HHC. While a majority of risk factors were represented in the Omaha System, additional terminologies are needed to comprehensively capture risk. Since most risk factors are documented in clinical notes, methods such as natural language processing are needed to extract them.
CONCLUSION: This study engaged clinicians to understand risk for deterioration during HHC. The results of our study support the development of an early warning system by providing a comprehensive list of risk factors grounded in clinician expertize and mapped to standardized terminologies.
© The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Entities:  

Keywords:  Omaha System; electronic health record; home health; natural language processing; nursing informatics; qualitative

Mesh:

Year:  2022        PMID: 35196369      PMCID: PMC9006696          DOI: 10.1093/jamia/ocac023

Source DB:  PubMed          Journal:  J Am Med Inform Assoc        ISSN: 1067-5027            Impact factor:   4.497


  32 in total

Review 1.  The role of standardized data and terminological systems in computerized clinical decision support systems: literature review and survey.

Authors:  Leila Ahmadian; Mariette van Engen-Verheul; Ferishta Bakhshi-Raiez; Niels Peek; Ronald Cornet; Nicolette F de Keizer
Journal:  Int J Med Inform       Date:  2010-12-17       Impact factor: 4.046

Review 2.  The Omaha System: a systematic review of the recent literature.

Authors:  Maxim Topaz; Nadya Golfenshtein; Kathryn H Bowles
Journal:  J Am Med Inform Assoc       Date:  2013-06-06       Impact factor: 4.497

3.  The Omaha System. Coded data that describe patient care.

Authors:  Jennifer H Garvin; Karen S Martin; Debee L Stassen; Kathryn H Bowles
Journal:  J AHIMA       Date:  2008-03

4.  Home Healthcare Clinical Notes Predict Patient Hospitalization and Emergency Department Visits.

Authors:  Maxim Topaz; Kyungmi Woo; Miriam Ryvicker; Maryam Zolnoori; Kenrick Cato
Journal:  Nurs Res       Date:  2020 Nov/Dec       Impact factor: 2.381

Review 5.  What can natural language processing do for clinical decision support?

Authors:  Dina Demner-Fushman; Wendy W Chapman; Clement J McDonald
Journal:  J Biomed Inform       Date:  2009-08-13       Impact factor: 6.317

6.  Mining clinical phrases from nursing notes to discover risk factors of patient deterioration.

Authors:  Zfania Tom Korach; Jie Yang; Sarah Collins Rossetti; Kenrick D Cato; Min-Jeoung Kang; Christopher Knaplund; Kumiko O Schnock; Jose P Garcia; Haomiao Jia; Jessica M Schwartz; Li Zhou
Journal:  Int J Med Inform       Date:  2019-12-14       Impact factor: 4.046

7.  The Time is Now: Informatics Research Opportunities in Home Health Care.

Authors:  Paulina S Sockolow; Kathryn H Bowles; Maxim Topaz; Gunes Koru; Ragnhild Hellesø; Melissa O'Connor; Ellen J Bass
Journal:  Appl Clin Inform       Date:  2021-02-17       Impact factor: 2.342

8.  Nursing documentation of symptoms is associated with higher risk of emergency department visits and hospitalizations in homecare patients.

Authors:  Maxim Topaz; Theresa A Koleck; Nicole Onorato; Arlene Smaldone; Suzanne Bakken
Journal:  Nurs Outlook       Date:  2020-12-29       Impact factor: 3.250

Review 9.  Selfie consents, remote rapport, and Zoom debriefings: collecting qualitative data amid a pandemic in four resource-constrained settings.

Authors:  Mark Donald C Reñosa; Chanda Mwamba; Ankita Meghani; Nora S West; Shreya Hariyani; William Ddaaki; Anjali Sharma; Laura K Beres; Shannon McMahon
Journal:  BMJ Glob Health       Date:  2021-01

10.  How to Improve Information Technology to Support Healthcare to Address the COVID-19 Pandemic: an International Survey with Health Informatics Experts.

Authors:  Max Topaz; Laura-Maria Peltonen; James Mitchell; Dari Alhuwail; Seyedeh-Samin Barakati; Adrienne Lewis; Hans Moen; Sai Pavan Kumar Veeranki; Lori Block; Tracie Risling; Charlene Ronquillo
Journal:  Yearb Med Inform       Date:  2021-04-21
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