About
77
Publications
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4,702
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Current institution
Additional affiliations
July 1987 - present
University of Toronto University Health Network
Position
- Director OpenLab
Description
- Internal Medicine Consultant and Director of OpenLab, a Design and Innovation group at University Health Network developing creative solutions for Health Care Systems and their Social Determinants.
Publications
Publications (77)
The COVID 19 pandemic necessitated a rapid implementation of virtual care within the Canadian healthcare system generating previously unimagined levels of virtual care uptake and accessibility. The transition to virtual care provided benefits for both patients and providers including a reduction in cost, time saved, and greater protection from infe...
Background:
Patients with acute heart failure are frequently or systematically hospitalized, often because the risk of adverse events is uncertain and the options for rapid follow-up are inadequate. Whether the use of a strategy to support clinicians in making decisions about discharging or admitting patients, coupled with rapid follow-up in an ou...
Introduction
Geriatric assessment (GA) provides information on key health domains of older adults and is recommended to help inform cancer treatment decisions and cancer care. However, GA is not feasible in many health institutions due to lack of geriatric staff and/or resources. To increase accessibility to GA and improve treatment decision making...
Despite growing international interest, the caregiving body of literature lacks a recent understanding of young carers’ experiences and their contact with the health care system. We conducted a systematic review of qualitative studies to (1) synthesize more recent qualitative evidence on young carers’ experience, and (2) to identify how these young...
Background:
Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable...
Our qualitative descriptive study compared how older patients and their informal caregivers experienced the care transition from acute care or rehabilitation to home. We recruited patients 65 years of age or older, or their informal caregivers, from in-patient units within acute care hospitals and rehabilitation facilities to participate in semi-st...
BACKGROUND: Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable...
BACKGROUND
Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable a...
Purpose
The use of telemedicine, a part of ‘Virtual Care’, is rapidly entering mainstream clinical practice. The ideal curriculum for educating physicians to practice in this emerging field has not been established. We examined the literature to evaluate published curricula for quality and comprehensiveness through the lens of Competency-Based Medi...
Background
Heart failure patients often present with frailty and/or multi-morbidity, complicating care and service delivery. The Chronic Care Model (CCM) is a useful framework for designing care for complex patients. It assumes responsibility of several actors, including frontline providers and health-care administrators, in creating conditions for...
This joint Canadian Heart Failure Society (CHFS) and the CCS Heart Failure guidelines report has been developed to provide a pan-Canadian snapshot of the current state of clinic-based ambulatory heart failure (HF) care in Canada with specific reference to elements and processes of care associated with quality and high performing health systems. It...
In this update, we focus on selected topics of high clinical relevance for health care providers who treat patients with heart failure (HF), on the basis of clinical trials published after 2017. Our objective was to review the evidence, and provide recommendations and practical tips regarding the management of candidates for the following HF therap...
Background: Older adults living in long term care, rehabilitation hospitals, and seniors' residences often experience reduced mobility, sometimes resulting in confinement indoors and isolation, which can introduce or aggravate symptoms of depression, anxiety, loneliness, and apathy. As Virtual Reality (VR) technologies become increasingly accessibl...
Background:
Many patients have difficulty understanding and adhering to discharge instructions once home from hospital. We assessed patient and family caregiver perspectives on factors that influence understanding of and adherence to discharge instructions.
Methods:
We conducted a qualitative study using semistructured interviews of participants...
Background:
Geographic factors may influence cardiovascular disease outcomes in Canada. Circulatory diseases are a major reason for higher population mortality rates in Northern Ontario, but it is unknown if hospitalized patients with cardiovascular disease experience differential outcomes compared with those in the South.
Methods:
We examined 3...
Background
The management of complex, multi-morbid patients is challenging for solo primary care providers (PCPs) with limited access to resources. The primary objective of the intervention was to reduce the overall rate of Emergency Department (ED) visits among patients in participating practices.
Methods and findings
An interrupted time series d...
Qualitative interview guide.
(DOCX)
Common reasons for contacting SCOPE.
(DOCX)
Monthly calls to each element of the SCOPE intervention.
(TIF)
Monthly patient results viewed in PRO.
(TIF)
Outcomes of contacts to SCOPE (n = 1,588).
(TIF)
Specialist referrals (n = 282).
* Other includes: hematology, ENT, pain management, allergy, plastic surgery, pediatrics, nephrology, ophthalmology and respirology.
(TIF)
Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reasses...
With an aging population and a healthcare system that is overly reliant on providing expensive and sometimes problematic hospital-based care for older Canadians, driving improvements that promote elder-friendly care has never been more critical. The Acute Care for Elders (ACE) Strategy at Toronto's Mount Sinai Hospital is the focus of a pan-Canadia...
Background:
Patient-centered discharge tools provide an opportunity to engage patients, enhance patient understanding, and improve capacity for self-care and postdischarge outcomes.
Purpose:
To review studies that engaged patients in the design or delivery of discharge instruction tools and that tested their effect among hospitalized patients....
Background:
A small proportion of patients accounts for a very high proportion of healthcare utilization. Accurate pre-emptive identification may facilitate tailored intervention. We sought to determine whether Machine Learning techniques using text from a family practice Electronic Medical Record (EMR) can be used to predict future high Emergency...
Background:
Isolation precautions have negative effects on patient safety, psychological well-being, and healthcare worker contact. However, it is not known whether isolation precautions affect certain hospital-related outcomes.
Objective:
To examine the effect of isolation precautions on hospital-related outcomes and cost of care.
Design:
Ret...
Background:
Hip fractures are associated with significant morbidity and mortality. Co-management models pairing orthopaedic surgeons with hospitalists or geriatricians may be effective at improving processes of care and outcomes such as length of stay (LOS) and cost. We set out to determine the effect of an integrated hip fracture co-management mo...
Objective: To describe the co-design process we undertook to create a patient-oriented discharge summary (PODS) with patients, caregivers, and providers. • Method: Descriptive report. • Results: We designed and produced a prototype PODS, based on best practices in information design, graphic design, and patient education. Through a co-design proces...
Communication gaps when patients transition from hospital to either home or community can be problematic. Partnership between Toronto Central Local Health Integration Network (TC LHIN) and OpenLab addressed this through the Patient-Oriented Discharge Summaries (PODS) project. From January through March 2015, eight hospital departments across Toront...
Unlabelled:
This paper focuses on successful engagement strategies in recruiting and retaining primary care physicians (PCPs) in a quality improvement project, as perceived by family physicians in small practices. Sustained physician engagement is critical for quality improvement (QI) aiming to enhance health system integration. Although there is...
The costs of healthcare in developed countries have seen a dramatic increase in tandem with the increasing utilization of diagnostic testing. As a result, Appropriate Use Criteria (AUC)-based practices have become more commonplace as a provider-driven solution to reducing unnecessary tests and procedures across various specialty societies. The AUC...
Background
Responding to concerns regarding the growth of cardiac testing, the American College of Cardiology Foundation (ACCF) published Appropriate Use Criteria (AUC) for various cardiac imaging modalities. Single modality cardiac imaging appropriateness has been reported but there have been no studies assessing the appropriateness of multiple im...
For hospitalized patients, the transition from hospital to home is frequently accompanied by a significant amount of information to absorb. The objective of this work was to engage patients, caregivers, and healthcare providers in codeveloping patient-oriented discharge instructions, (ie, a brief transition plan with information that patients want)...
The Canadian Cardiovascular Society Heart Failure (HF) Guidelines Program has generated annual HF updates, including formal recommendations and supporting Practical Tips since 2006. Many clinicians indicate they routinely use the Canadian Cardiovascular Society HF Guidelines in their daily practice. However, many questions surrounding the actual im...
Background: More than 1·5 billion people are affected by schistosomiasis or soil-transmitted helminthiasis. WHO's recommendations for mass drug administration (MDA) against these parasitic infections emphasise treatment of school-aged children, using separate treatment guidelines for these two helminthiases groups. We aimed to evaluate the cost-eff...
Two cases of strongyloidiasis hyperinfection are presented. Ivermectin was initially administered orally and per rectum pending the availability of subcutaneous (SC) preparations. In neither case did rectal suppositories of ivermectin achieve clinically meaningful serum values. Clinicians should use SC preparations of ivermectin as early as possibl...
The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides discussion on the management recommendations on 3 focused areas: (1) anemia; (2) biomarkers, especially natriuretic peptides; and (3) clinical trials that might change practice in the management of patients with heart failure. First, all patients with heart...
Importance
Hospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated.Objective
To determine whether a virtual ward—a...
Background:
Inpatients are visited by many health care providers daily; many cannot remember the name of even one member of their clinical care team. We provided inpatients with photographs of their clinicians and evaluated the impact on patient recall and communication with their health care providers.
Methods:
A concealed allocation, randomize...
Evidence exists that clinical outcomes improve for stroke patients admitted to specialized Stroke Units. The Toronto Western Hospital created a Neurovascular Unit (NVU) using beds from general internal medicine, Neurology and Neurosurgery to care for patients with stroke and acute neurovascular conditions. Using patient-level data for NVU-eligible...
The objective of this study was to explore health-care professionals’, health administrators’, and not-for-profit cancer organization representatives’ perceptions of lung cancer-related stigma and nihilism and the perceived impacts on funding and patient care. This is a qualitative descriptive study using semi-structured interviews, which was condu...
Background:
Smartphones are becoming ubiquitous in health care settings. The increased adoption of mobile technology such as smartphones may be attributed to their use as a point-of-care information source and to perceived improvements in clinical communication and efficiency. However, little is known about medical students' use of personal smartp...
Our Health Care Systems, especially our hospitals, were designed primarily to provide episodic care for acute occurrences of single diseases. With our aging population and the predominance of chronic diseases, highly integrated and coordinated care is required. This demands a “systems re-design”, not just making the old system better. Additionally,...
Background:
There is strong evidence that clinical outcomes are improved for stroke patients admitted to specialized Stroke Units. The Toronto Western Hospital (TWH) created a Neurovascular Unit (NVU) using resources from General Internal Medicine, Neurology, and Neurosurgery for patients with stroke and acute neurovascular conditions. Under resou...
Purpose: There is strong evidence that clinical outcomes are improved for stroke patients admitted to specialized stroke units, but little is known about the operational impact of creating a stroke unit. Without additional resources, beds are typically taken from internal medicine, neurology, and neurosurgery services to make up the new Neurovascul...
A current focus of healthcare organizations and legislation requires hospitals to place more importance on patient experience and satisfaction than ever before. Institutional patient satisfaction survey tools yield data that represent approximately 5% of patients and may not represent the typical patient experience. Moreover, our research demonstra...
This paper examines the long-standing operational issue of patients boarding in the emergency department (ED), who have been admitted to hospital (inpatient ‘boarders’). From this analysis we design a conceptual model that provides a roadmap to create sustainable improvements in ED waiting times. The conceptual model is built using system dynamics...
For patients with critical laboratory abnormalities, timely clinical alerts with decision support could improve management and reduce adverse events.
The authors developed a real-time clinical alerting system for critical laboratory abnormalities. The system sent alerts to physicians as text messages to a smartphone or alphanumeric pager. Decision...
Part of delivering quality care means providing it in a timely, efficient manner. Improving the efficiency of care requires measurement. The selection of appropriate indicators that are valid and responsive is crucial to focus improvement initiatives. Indicators of operational efficiency should be conceptually simple, generated in real time, calcul...
Communication between clinicians is hampered by the frequent difficulty in reaching the most responsible physician for a patient as well as the use of outdated methods such as numeric paging. The aim of this study was to evaluate the use of smartphones to improve communication on internal medicine wards.
At the Toronto General Hospital, residents w...
Timely access to emergency patient care is an important quality and efficiency issue. Reduced discharges of inpatients at weekends are a reality to many hospitals and may reduce hospital efficiency and contribute to emergency department (ED) congestion.
To evaluate the daily number of ED beds occupied by inpatients after evenly distributing inpatie...
Patients in the emergency department (ED) who have been admitted to hospital (inpatient "boarders") are associated with ED overcrowding. They are also a symptom of a hospital-wide imbalance between demand and supply of resources. We analyzed the trends of inpatient admissions, ED boarding volumes, lengths of stay and bed resources of 3 major admitt...
Rigorous evaluation of an intervention requires that its allocation be unbiased with respect to confounders; this is especially difficult in complex, system-wide healthcare interventions. We developed a short survey instrument to identify factors for a minimization algorithm for the allocation of a hospital-level intervention to reduce emergency de...
Candidate factors by change stages. Table lists 33 candidate factors by organizational change stages that the expert panel assessed across specified domains.
The objective of this study is to determine the effect of day of the week, holiday, team admission and rotation schedules, individual attending physicians and their length of coverage on daily team discharge rates.
We conducted a retrospective analysis of the General Internal Medicine (GIM) inpatient service at our institution for years 2005 and 20...
Effective and timely communication of information is essential for quality patient care. Information and communication technology tools have the potential to transform and enable health care processes to be more accurate, timely, and integrated. This study describes the development, implementation, and evaluation of an electronic whiteboard in a Ge...
Canadians are living longer with chronic medical conditions, which have led to an increasing complexity and volume of care for hospitalized patients. Effective in-patient care depends on the effective coordination of care through rapid and efficient communication between various care providers. A delay in coordinating this care has downstream effec...
Fundamental to the project's success was acceptance of MOE/MAR by UHN's physicians, yet many physicians questioned whether MOE/MAR would impede their ability to care for their patients. To ensure physician adoption, UHN presented MOE/MAR as a patient safety initiative from the beginning.
There are many reasons why most hospitals have not adopted physician order entry systems for medications. It is a costly endeavour (Kuperman and Gibson 2003) that can cause major disruptions to workflow for physicians, pharmacists and nurses. Yet, the technology can reduce medication errors, especially with sophisticated decision support. We have p...
BACKGROUND: Japanese medical education has undergone dramatic changes over the last 5 years. Clinical exercises and ambulatory-care training are now stressed to prepare medical students and residents for work in primary and continuing-care settings. For comparative purposes, we conducted a review of the undergraduate and residency training programs...
In ambulatory care settings, patients with limited English proficiency receive lower quality of care. Limited information is available describing outcomes for inpatients.
To investigate the effect of English proficiency on length of stay (LOS) and in-hospital mortality.
Retrospective analysis of administrative data at 3 tertiary care teaching hospi...
A 40-year-old woman with previous parathyroidectomy for adenoma was found to have a serum calcium level of 5.35 mmol l-1 (21.4 mg dl-1). Inadvertent calcium overdose had occurred because of her mistaken belief that if some prescribed calcium was good, then more was better. Her misconception is in contrast with that of patients with Münchausen's syn...
In the absence of good clinical evidence from a randomized trial, the authors performed a decision analysis to determine the potential value of early elective surgery (OPNOW) for patients with left-sided Staphylococcus aureus infective endocarditis. Initial impressions (before performance of decision analysis) and initial runs at the formal models...
In order to gain insight into the impact that decision analysis has had on clinical practice, we presented a published report on the utility of renal biopsy for patients with idiopathic nephrotic syndrome to a group of nephrologists and residents at a teaching hospital. Although the analysis showed that the decision to biopsy or use empiric steroid...
In this article, we describe a multifactorial cardiac risk index that can be used to assess patients undergoing noncardiac surgery. The index is a modified version of an index that was previously generated by Goldman and coworkers on a set of 1001 consecutive patients and prospectively validated in our clinical setting (a general medical consultati...
The authors prospectively studied 455 consecutive patients referred to the general medical consultation service for cardiac risk assessment prior to non-cardiac surgery, in order to validate a previously derived multifactorial index in their clinical setting. They also tested a version of the index that they had modified to reflect factors they bel...
Between October 30 and November 5, 1980, the Professional Association of Interns and Residents of Ontario called a strike of house staff in Ontario's teaching hospitals. The authors obtained data concerning utilization of laboratory tests and radiology procedures during that period and for the same days 2 weeks before and after the strike. During t...
Quality of life and quality-adjusted survival were measured for a cohort of 73 patients maintained on long-term parenteral nutrition at home (HPN) for periods ranging from six months to 12 years. Quality-adjusted survival was also modeled (although not directly observed) for this cohort under alternative therapeutic strategies (e.g., parenteral nut...
We performed an economic evaluation of a home parenteral nutrition (HPN) program by measuring the incremental costs and health outcomes for a cohort of 73 patients treated at our institution from November 1970 to July 1982.
Over a 12‐year time frame, we estimate that HPN resulted in a net savings in health care costs of $19,232 per patient and an i...
