Donna Espadas

Publications of Donna Espadas

• Towards successful coordination of electronic health record based-referrals: a qualitative analysis.

  Authors: Sylvia J Hysong, Adol Esquivel, Dean F Sittig, Lindsey A Paul, Donna Espadas, Simran Singh, Hardeep Singh

  Implementation science : IS. 07/2011; 6:84.

  ABSTRACT: Successful subspecialty referrals require considerable coordination and interactive communication among the primary care provider (PCP), the subspecialist, and the patient, which may beABSTRACT: Successful subspecialty referrals require considerable coordination and interactive communication among the primary care provider (PCP), the subspecialist, and the patient, which may be challenging in the outpatient setting. Even when referrals are facilitated by electronic health records (EHRs) (i.e., e-referrals), lapses in patient follow-up might occur. Although compelling reasons exist why referral coordination should be improved, little is known about which elements of the complex referral coordination process should be targeted for improvement. Using Okhuysen & Bechky's coordination framework, this paper aims to understand the barriers, facilitators, and suggestions for improving communication and coordination of EHR-based referrals in an integrated healthcare system. We conducted a qualitative study to understand coordination breakdowns related to e-referrals in an integrated healthcare system and examined work-system factors that affect the timely receipt of subspecialty care. We conducted interviews with seven subject matter experts and six focus groups with a total of 30 PCPs and subspecialists at two tertiary care Department of Veterans Affairs (VA) medical centers. Using techniques from grounded theory and content analysis, we identified organizational themes that affected the referral process. Four themes emerged: lack of an institutional referral policy, lack of standardization in certain referral procedures, ambiguity in roles and responsibilities, and inadequate resources to adapt and respond to referral requests effectively. Marked differences in PCPs' and subspecialists' communication styles and individual mental models of the referral processes likely precluded the development of a shared mental model to facilitate coordination and successful referral completion. Notably, very few barriers related to the EHR were reported. Despite facilitating information transfer between PCPs and subspecialists, e-referrals remain prone to coordination breakdowns. Clear referral policies, well-defined roles and responsibilities for key personnel, standardized procedures and communication protocols, and adequate human resources must be in place before implementing an EHR to facilitate referrals.

• Follow-up actions on electronic referral communication in a multispecialty outpatient setting.

  Authors: Hardeep Singh, Adol Esquivel, Dean F Sittig, Daniel Murphy, Himabindu Kadiyala, Rachel Schiesser, Donna Espadas, Laura A Petersen

  Journal of general internal medicine. 01/2011; 26(1):64-9.

  Electronic health records (EHR) enable transmission and tracking of referrals between primary-care practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronicElectronic health records (EHR) enable transmission and tracking of referrals between primary-care practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronic referral communication in a large multispecialty VA facility. We retrieved outpatient referrals to five subspecialties between October 2006 and December 2007, and queried the EHR to determine their status: completed, discontinued (returned to PCP), or unresolved (no action taken by subspecialist). All unresolved referrals, and random samples of discontinued and completed referrals were reviewed to determine whether subspecialists took follow-up actions (i.e., schedule appointments anytime in the future) within 30 days of referral-receipt. For referrals without timely follow-up, we determined whether inaction was supported by any predetermined justifiable reasons or associated with certain referral characteristics. We also reviewed if PCPs took the required action on returned information. Of 61,931 referrals, 22,535 were discontinued (36.4%), and 474 were unresolved (0.8%). We selected 412 discontinued referrals randomly for review. Of these, 52% lacked follow-up actions within 30 days. Appropriate justifications for inaction were documented in 69.8% (150/215) of those without action and included lack of prerequisite testing by the PCP and subspecialist opinion that no intervention was required despite referral. We estimated that at 30 days, 6.3% of all referrals were associated with an unexplained lack of follow-up actions by subspecialists. Conversely, 7.4% of discontinued referrals returned to PCPs were associated with an unexplained lack of follow-up. Although the EHR facilitates transmission of valuable information at the PCP-subspecialist interface, unexplained communication breakdowns in the referral process persist in a subset of cases.

• Ten strategies to improve management of abnormal test result alerts in the electronic health record.

  Authors: Hardeep Singh, Lindsey Wilson, Brian Reis, Mona K Sawhney, Donna Espadas, Dean F Sittig

  Journal of patient safety. 06/2010; 6(2):121-3.

• Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

  Authors: Hardeep Singh, Eric J Thomas, Dean F Sittig, Lindsey Wilson, Donna Espadas, Myrna M Khan, Laura A Petersen

  The American journal of medicine. 03/2010; 123(3):238-44.

  Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examinedFollow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions. We studied 4 alerts: hemoglobin A1c > or =15%, positive hepatitis C antibody, prostate-specific antigen > or =15 ng/mL, and thyroid-stimulating hormone > or =15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up. Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84). Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

• Research paper: Provider management strategies of abnormal test result alerts: a cognitive task analysis.

  Authors: Sylvia J. Hysong, Mona K. Sawhney, Lindsay Wilson, Dean F. Sittig, Donna Espadas, Traber Davis, Hardeep Singh

  JAMIA. 01/2010; 17:71-77.

• Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication.

  Authors: Hardeep Singh, Lindsey Wilson, Laura A Petersen, Mona K Sawhney, Brian Reis, Donna Espadas, Dean F Sittig

  BMC medical informatics and decision making. 12/2009; 9(1):49.

  ABSTRACT: BACKGROUND: Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positiveABSTRACT: BACKGROUND: Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response. METHODS: Using both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention. RESULTS: Data from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p<0.01) and was sustained at month 4 following the intervention. CONCLUSIONS: Electronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems.

• Improving outpatient safety through effective electronic communication: a study protocol.

  Authors: Sylvia Hysong, Mona Sawhney, Lindsey Wilson, Dean Sittig, Adol Esquivel, Monica Watford, Traber Davis, Donna Espadas, Hardeep Singh

  Implementation science : IS. 09/2009; 4(1):62.

  ABSTRACT: BACKGROUND: Health information technology and electronic medical records (EMRs) are potentially powerful systems-based interventions to facilitate diagnosis and treatment because theyABSTRACT: BACKGROUND: Health information technology and electronic medical records (EMRs) are potentially powerful systems-based interventions to facilitate diagnosis and treatment because they ensure the delivery of key new findings and other health related information to the practitioner. However, effective communication involves more than just information transfer; despite a state of the art EMR system, communication breakdowns can still occur. [1-3] In this project, we will adapt a model developed by the Systems Engineering Initiative for Patient Safety (SEIPS) to understand and improve the relationship between work systems and processes of care involved with electronic communication in EMRs. We plan to study three communication activities in the Veterans Health Administration's (VA) EMR: electronic communication of abnormal imaging and laboratory test results via automated notifications (i.e., alerts); electronic referral requests; and provider-to-pharmacy communication via computerized provider order entry (CPOE). Aim: Our specific aim is to propose a protocol to evaluate the systems and processes affecting outcomes of electronic communication in the computerized patient record system (related to diagnostic test results, electronic referral requests, and CPOE prescriptions) using a human factors engineering approach, and hence guide the development of interventions for work system redesign. DESIGN: This research will consist of multiple qualitative methods of task analysis to identify potential sources of error related to diagnostic test result alerts, electronic referral requests, and CPOE; this will be followed by a series of focus groups to identify barriers, facilitators, and suggestions for improving the electronic communication system. Transcripts from all task analyses and focus groups will be analyzed using methods adapted from grounded theory and content analysis.

• Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

  Authors: Hardeep Singh, Eric J Thomas, Shrinidi Mani, Dean Sittig, Harvinder Arora, Donna Espadas, Myrna M Khan, Laura A Petersen

  Archives of internal medicine. 09/2009; 169(17):1578-86.

  BACKGROUND: Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) thatBACKGROUND: Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem. METHODS: We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up. RESULTS: Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (>1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment. CONCLUSIONS: Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area.

• Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study.

  Authors: Hardeep Singh, Shrinidi Mani, Donna Espadas, Nancy Petersen, Veronica Franklin, Laura A Petersen

  Archives of internal medicine. 06/2009; 169(10):982-9.

  BACKGROUND: Although several types of computerized provider order entry (CPOE)-related errors may occur, errors related to inconsistent information within the same prescription (ie, mismatch betweenBACKGROUND: Although several types of computerized provider order entry (CPOE)-related errors may occur, errors related to inconsistent information within the same prescription (ie, mismatch between the structured template and the associated free-text field) have not been described, to our knowledge. We determined the nature and frequency of such errors and identified their potential predictive variables. METHODS: In this prospective study, we enrolled pharmacists to report prescriptions containing inconsistent communication over a 4-month period at a tertiary care facility. We also electronically retrieved all prescriptions written during the study period containing any comments in the free-text field and then randomly selected 500 for manual review to determine inconsistencies between free-text and structured fields. Of these, prescriptions without inconsistencies were categorized as controls. Data on potentially predictive variables from reported and unreported errors and controls were collected. For all inconsistencies, we determined their nature (eg, drug dosage or administration schedule) and potential harm and used multivariate logistic regression models to identify factors associated with errors and harm. RESULTS: Of 55 992 new prescriptions, 532 (0.95%) were reported to contain inconsistent communication, a rate comparable to that obtained from the unreported group. Drug dosage was the most common inconsistent element among both groups. Certain medications were more likely associated with errors, as was the inpatient setting (odds ratio, 3.30; 95% confidence interval, 2.18-5.00) and surgical subspecialty (odds ratio, 2.45; 95% confidence interval, 1.57-3.82). About 20% of errors could have resulted in moderate to severe harm, for which significant independent predictors were found. CONCLUSIONS: Despite standardization of data entry, inconsistent communication in CPOE poses a significant risk to safety. Improving the usability of the CPOE interface and integrating it with workflow may reduce this risk.

• Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication

  Authors: Hardeep Singh, Lindsey Wilson, Laura Petersen, Mona Sawhney, Brian Reis, Donna Espadas, Dean Sittig

  BMC Medical Informatics and Decision Making. 01/2009;

  Abstract Background Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positiveAbstract Background Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response. Methods Using both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention. Results Data from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p < 0.01) and was sustained at month 4 following the intervention. Conclusion Electronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems.

• Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain?

  Authors: Hardeep Singh, Eric J. Thomas, Dean F. Sittig, Lindsey Wilson, Donna Espadas, Myrna M. Khan, Laura A. Petersen

  The American Journal of Medicine.

  BackgroundFollow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification.BackgroundFollow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions.MethodsWe studied 4 alerts: hemoglobin A1c ≥15%, positive hepatitis C antibody, prostate-specific antigen ≥15 ng/mL, and thyroid-stimulating hormone ≥15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up.ResultsBetween May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84).ConclusionsSafety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

• Improving outpatient safety through effective electronic communication: a study protocol

  Authors: Sylvia J Hysong, Mona K Sawhney, Lindsey Wilson, Dean F Sittig, Adol Esquivel, Monica Watford, Traber Davis, Donna Espadas, Hardeep Singh

• Provider management strategies of abnormal test result alerts: a cognitive task analysis.

  Authors: Sylvia J Hysong, Mona K Sawhney, Lindsay Wilson, Dean F Sittig, Donna Espadas, Traber Davis, Hardeep Singh

  Journal of the American Medical Informatics Association : JAMIA. 17(1):71-7.

  Electronic medical records (EMRs) facilitate abnormal test result communication through "alert" notifications. The aim was to evaluate how primary care providers (PCPs) manage alerts related toElectronic medical records (EMRs) facilitate abnormal test result communication through "alert" notifications. The aim was to evaluate how primary care providers (PCPs) manage alerts related to critical diagnostic test results on their EMR screens, and compare alert-management strategies of providers with high versus low rates of timely follow-up of results. 28 PCPs from a large, tertiary care Veterans Affairs Medical Center (VAMC) were purposively sampled according to their rates of timely follow-up of alerts, determined in a previous study. Using techniques from cognitive task analysis, participants were interviewed about how and when they manage alerts, focusing on four alert-management features to filter, sort and reduce unnecessary alerts on their EMR screens. Provider knowledge of alert-management features ranged between 4% and 75%. Almost half (46%) of providers did not use any of these features, and none used more than two. Providers with higher versus lower rates of timely follow-up used the four features similarly, except one (customizing alert notifications). Providers with low rates of timely follow-up tended to manually scan the alert list and process alerts heuristically using their clinical judgment. Additionally, 46% of providers used at least one workaround strategy to manage alerts. Considerable heterogeneity exists in provider use of alert-management strategies; specific strategies may be associated with lower rates of timely follow-up. Standardization of alert-management strategies including improving provider knowledge of appropriate tools in the EMR to manage alerts could reduce the lack of timely follow-up of abnormal diagnostic test results.