Mindy E Flanagan

• PhD
• Indiana University – Purdue University Indianapolis

Background Electronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresp...

Background People who support Veterans as they transition from their military service into civilian life may be at an increased risk of psychological distress. Existing studies focus primarily on paid family caregivers, but few studies include spouses and informal non-family “care partners.” We sought to identify key challenges faced by care partne...

578 Background: High levels of symptoms and distress in cancer patients are linked to negative outcomes related to treatment adherence, healthcare utilization, quality of life, and survival. As such, psychosocial distress screening is now mandated in the American College of Surgeons Commission on Cancer accreditation standards. A growing body of ev...

Objective: This article examines the relationship between inpatient mental health units' adherence to recovery-oriented care and 30-day patient readmission. Method: The sample included patients admitted to one of 34 Veterans Health Administration inpatient mental health units. Recovery-oriented care was assessed using interviews and site visits....

Prior studies have demonstrated disruption to outpatient mental health services after the onset of the COVID-19 pandemic. Inpatient mental health services have received less attention. The current study utilized an existing cohort of 33 Veterans Health Affairs (VHA) acute inpatient mental health units to examine disruptions to inpatient services. I...

Objective: The current article describes efforts to develop and test a measure of recovery-oriented inpatient care. Method: The Recovery-oriented Acute INpatient (RAIN) scale was based on prior literature and current Veterans Health Administration (VHA) policy and resources and further revised based on data collection from 34 VHA acute inpatient...

End-of-shift handoffs occur when physicians transfer care responsibilities from one shift to another. Typically viewed as a straightforward exchange of information, we argue that several contextually relevant factors shape the communication behaviors of outgoing and incoming residents during handoffs. Digital recordings and transcripts of resident...

Objective: Clinician burnout in healthcare is extensive and of growing concern. In mental health and rehabilitation settings, research on interventions to improve burnout and work engagement is limited and rarely addresses organizational drivers of burnout. This study sought to elaborate on the organizational influence of burnout and work engagemen...

Background Heart failure (HF) is a growing public health problem in the United States. Implantable cardiac resynchronization therapy (CRT) devices reduce mortality and morbidity, and remote monitoring (RM) of these devices improves outcomes. However, patient RM adherence is low, due in part to lack of access to their RM data. Providing these data t...

Patients with atrial fibrillation (AF) demonstrate persistent knowledge gaps regarding their condition and a substandard adherence to oral anticoagulant (OAC) medication, which contribute to thromboembolic stroke and other clot-related complications. Tailored patient education and medication reminders may help reduce these negative health outcomes....

An online survey was created and deployed from July 2 to July 20, 2020. Respondents received an invitation to participate in the survey from school districts, Parkview Sports Medicine, parent-teacher organizations, and via social media. Respondents were 18 years or older and had one or more children under 18 years in their household. A total of 947...

Background Pharmacodynamics and pharmacogenetics are being explored in pharmacological treatment response for major depressive disorder (MDD). Interactions between genotype and treatment response may be dose dependent. In this study, we examined whether MDD patients with Met/Met, Met/Val, and Val/Val COMT genotypes differed in their response to bup...

Objective Our primary objectives were to examine adherence rates across two technologies (e-prescribing software and smart pill bottle) with cross-validation from alert-triggered messaging within the patient electronic health record (EHR) portal and to explore the benefits and challenges faced by atrial fibrillation (AF) patients in using a smart p...

BACKGROUND: Geographic cohorting (GCh) localizes hospitalists to a unit. Our objective was to compare the GCh and non-GCh workday. METHODS: In an academic, Midwestern hospital we observed hospitalists in GCh and non-GCh teams. Time in patient rooms was considered direct care; other locations were considered ‘indirect’ care. Geotracking identified t...

Objective: Researchers conduct studies with selection biases, which may limit generalizability and outcomes of intervention research. In this methodological reflection, we examined demographic and health characteristics of implantable cardioverter defibrillator patients who were excluded from an informatics intervention due to lack of access to a...

BACKGROUND The widespread availability and cost-effectiveness of new-wave, software-based Audience Response Systems (ARSs) has expanded the possibilities of collecting health data from hard-to-reach populations, including youth. However, with all survey methods, biases in the data may exist because of participant nonresponse. OBJECTIVE Our goals w...

Background: The widespread availability and cost-effectiveness of new-wave software-based audience response systems (ARSs) have expanded the possibilities of collecting health data from hard-to-reach populations, including youth. However, with all survey methods, biases in the data may exist because of participant nonresponse. Objective: The aim...

BACKGROUND Background: High rates of mental illness, stress, and suicidality among teens represent a major public health concern in the United States; however, rates of treatment remain low, partially due to barriers that could be mitigated with effective, evidence-based telemental health (TMH) resources. OBJECTIVE Objective: TMH resource usage by...

Background: High rates of mental illness, stress, and suicidality among teens constitute a major public health concern in the United States. However, treatment rates remain low, partially because of barriers that could be mitigated with tech-based telemental health (TMH) resources, separate from or in addition to traditional care. Objective: Thi...

Background Poor communication during end-of-shift transfers of care (handoffs) is associated with safety risks and patient harm. Despite the common perception that handoffs are largely a one-way transfer of information, researchers have documented that they are complex interactions, guided by implicit social norms and mental frameworks. Objectives...

Background Handoff education is both formal and informal and varies widely across medical school and residency training programs. Despite many efforts to improve clinical handoffs, little evidence has shown meaningful improvement. The objective of this study was to identify residents’ perspectives and develop a deeper understanding on the necessary...

Consultations are a critical part of healthcare for many patients; however, they pose macrocognitive challenges at both individual and system levels. Coordination between primary care and specialty clinics is challenging, because information must be shared across clinics, roles, and time. We conducted a study of the consultations process in the U.S...

Objectives To compare activities and field descriptions of clinical champions across three levels of stroke centers. Methods A cross-sectional qualitative study using quota sampling was conducted. The setting for this study was 38 acute stroke centers based in US Veterans Affairs Medical Centers with 8 designated as Primary, 24 as Limited Hours, a...

Supplementary_Table – Supplemental material for A qualitative study of clinical champions in context: Clinical champions across three levels of acute care

Introduction A sizeable number of youth are currently struggling with anxiety, depression, and suicidal thoughts, yet many will not receive treatment. We sought to better understand if immediate response technology (IRT) could be used to gather mental health care data and educate youth on telemental health (TMH) resources. Methods Using an IRT imb...

Background: During medical referrals, communication barriers between referring and consulting outpatient clinics delay patients' access to health care. One notable opportunity for reducing these barriers is improved usefulness and usability of electronic medical consultation order forms. The cognitive systems engineering (CSE) design approach focu...

Background/aims The idea that champions are crucial to effective healthcare-related implementation has gained broad acceptance; yet the champion construct has been hampered by inconsistent use across the published literature. This integrative review sought to establish the current state of the literature on champions in healthcare settings and brin...

Supplementary Material, S1_Figure_ – Inside help: An integrative review of champions in healthcare-related implementation

Background: Poor-quality handoffs have been associated with serious patient consequences. Researchers and educators have answered the call with efforts to increase system safety and resilience by supporting handoffs using increased communication standardization. The focus on strategies for formalizing the content and delivery of patient handoffs h...

Objectives Our objectives were to measure experts’ opinions and develop consensus via the Delphi process on the barriers, applications, and concerns associated with telemental health (TMH) for youth. Materials and methods We delivered 3 online surveys over 2 months in Summer, 2016–2025 adult experts, including adults who experienced youth depressi...

Background Despite health care access challenges among underserved populations, patients, providers, and staff at community health clinics (CHCs) have developed practices to overcome limited access. These “positive deviant” practices translate into organizational policies to improve health care access and patient experience. Objective To identify...

For some individuals who live with chronic heart failure (CHF), cardiac implantable electronic devices (CIEDs) offer lifesaving therapy. Remote monitoring data from CIEDs are transmitted on a routine schedule for highly trained clinical staff to review. However, the remote monitoring data and clinical interpretations are not directly accessible to...

Background: Provider burnout is a critical problem in mental health services. Contributing factors have been explicated across three domains: personal, job and organizational characteristics. Of these, organizational characteristics, including workplace environment, appear to be particularly important given that most interventions addressing burnou...

We assessed the usability of consultation order templates and identified problems to prioritize in design efforts for improving referral communication. With a sample of 26 consultation order templates, three evaluators performed a usability heuristic evaluation. The evaluation used 14 domain-independent heuristics and the following three supplement...

Successful implementation of evidence-based practices requires valid, yet practical fidelity monitoring. This study compared the costs and acceptability of three fidelity assessment methods: on-site, phone, and expert-scored self-report. Thirty-two randomly selected VA mental health intensive case management teams completed all fidelity assessments...

Provider competence may affect the impact of a practice. The current study examined this relationship in sixty-three providers engaging in Illness Management and Recovery with 236 consumers. Improving upon previous research, the present study utilized a psychometrically validated competence measure in the ratings of multiple Illness Management and...

This poster describes a project to improve understanding of the challenges associated with managing consultations in the Veterans Health Administration (VHA). We conducted interviews and observations with primary care providers and specialists at two VHA facilities. Using qualitative analysis, we identified cognitive requirements, challenges associ...

Objectives: Prior research found preliminary effectiveness for Burnout Reduction: Enhanced Awareness, Tools, Handouts, and Education (BREATHE), a daylong workshop for reducing burnout among behavioral health providers. Using a longer follow-up compared with prior research, this study compared the effectiveness of BREATHE and a control condition....

Background: Tools and procedures designed to improve end-of-shift handoffs through standardization of processes and reliance on technology may miss contextually sensitive information about anticipated events that emerges during face-to-face handoff interactions. Such information, what we refer to as anticipatory management communication (AMC), is n...

Shift change handoffs are known to be a point of vulnerability in the quality, safety and outcomes of healthcare. Despite numerous efforts to improve handoff reliability, few interventions have produced lasting change. Although the opportunity to ask questions during patient handoff has been required by some regulatory bodies, the function of quest...

Assertive community treatment is known for improving consumer outcomes, but is difficult to implement. On-site fidelity measurement can help ensure model adherence, but is costly in large systems. This study compared reliability and validity of three methods of fidelity assessment (on-site, phone-administered, and expert-scored self-report) using a...

The aim of this mixed-methods study was to identify ways that professional burnout may affect clinical work and consumer outcomes. Clinicians (N=120) participating in a burnout intervention trial completed a survey before the intervention, rating their level of burnout and answering open-ended questions about how burnout may affect their work. Resp...

This paper describes an effort to design and evaluate persuasive educational materials for colorectal cancer (CRC) screening. Although CRC screening is highly effective, screening rates in the US remain low. Educational materials represent one strategy for educating patients about screening options and increasing openness to screening. We developed...

Background: Inpatient satisfaction is a key element of hospital pay-for-performance programs. Communication and pain management are known to influence results, but additional factors may affect satisfaction scores. We tested the hypothesis that patient factors and outcome parameters not considered previously are clinically important drivers of inp...

This article identifies sources of variation in clinical workflow and implications for the design and implementation of electronic clinical decision support. Sources of variation in workflow were identified via rapid ethnographic observation, focus groups, and interviews across a total of eight medical centers in both the Veterans Health Administra...

We formed a collaborative to spread effective MRSA prevention strategies. We conducted a two-phase, multisite, quasi-experimental study of seven hospital systems (11 hospitals) in IN, MT, ME and Ontario, Canada over six years. Patients with prior MRSA were identified at admission using regional health information exchange data. We developed a syste...

Challenges persist on how to effectively integrate the electronic health record (EHR) into patient visits and clinical workflow, while maintaining patient-centered care. Our goal was to identify variations in, barriers to, and facilitators of the use of the US Department of Veterans Affairs (VA) EHR in ambulatory care workflow in order better to un...

The rapid change in healthcare has focused attention on the necessary development of a next-generation electronic health record (EHR) to support system transformation and more effective patient-centered care. The Department of Veterans Affairs (VA) is developing plans for the next-generation EHR to support improved care delivery for veterans. To un...

Background Healthcare professionals develop workarounds rather than using electronic health record (EHR) systems. Understanding the reasons for workarounds is important to facilitate user-centered design and alignment between work context and available health information technology tools. Objective To examine both paper- and computer-based workarou...

Transfers of care, also known as handovers, remain a substantial patient safety risk. Although research on handovers has been done since the 1980s, the science is incomplete. Surprisingly few interventions have been rigorously evaluated and, of those that have, few have resulted in long-term positive change. Researchers, both in medicine and other...

U.S. healthcare requires major redesign of its delivery systems, finances, and incentives. Healthcare operations, leadership, and payors are increasingly recognizing the need for community-business-research partnerships to transform healthcare. New models of continuous learning, research, and development should help focus and sustain redesign effor...

Usability Survey Questions and Groupings. A list of the usability survey questions and how they were grouped.

Workflow Integration Survey. A list of the 12 items that comprise the Workload Integration Survey. Participants rate their responses to the items using a Likert-type scale.

Based on barriers to the use of computerized clinical decision support (CDS) learned in an earlier field study, we prototyped design enhancements to the Veterans Health Administration's (VHA's) colorectal cancer (CRC) screening clinical reminder to compare against the VHA's current CRC reminder. In a controlled simulation experiment, 12 primary car...

With the United States national goal and incentive program to transition from paper to electronic health records (EHRs), healthcare organizations are increasingly implementing EHRs and other related health information technology (IT). However, in institutions which have long adopted these computerized systems, such as the Veterans Health Administra...

Because bundle implementation in intensive care units to reduce methicillin-resistant Staphylococcus aureus is challenging, we con- ducted in-depth interviews with implementation teams at 5 participating hospitals. Key lessons learned across hospitals included the following: maintain management support, engage frontline staff, build the right multi...

UK and US military personnel appear to have different health profiles yet direct comparisons of health status and deployment exposures between US and UK military populations have never been performed. To compare US and UK military personnel deployed to the 1991 Persian Gulf War (PGW) for rates of symptom reporting, medical conditions and health sta...

Health care-associated infections (HAIs) are a leading cause of death in United States health care settings, with an overall estimated annual incidence of 1.7 million. As antimicrobial resistance has increased, so too have efforts to reduce HAI rates. The objective of this study was to identify commonly cited lessons learned across a wide variety o...

There has been increasing interest and an upsurge in efforts to prevent hospital-associated infections (HAIs), a leading cause of death in the United States. This study was conducted to assess current strategies and efforts of HAI reduction initiatives in hospitals. HAI reduction initiatives and factors influencing institutional participation in th...

Despite reform efforts, today's healthcare system faces multiple challenges. Limitations of the current system result in major gaps between evidence and practice, suboptimal quality, inequitable patterns of utilization, inadequate safety and reliability, and unsustainable cost increases. Furthermore, there are major problems of overuse, underuse, a...

Interventions that focus on improving computerized clinical decision support (CDS) demonstrate that successful workflow integration can increase the adoption and use of CDS. However, metrics for assessing workflow integration in clinical settings are not well established. The goal of this study was to develop and validate a survey to assess the ext...

During a handoff, communication errors can lead to adverse events and suboptimal patient care. As a result, many institutions want to redesign their handoff processes, but have little specific guidance from the literature. We examined two approaches to nursing end-of-shift reports both taped and written, to identify specific factors limiting and fa...

In concept and practice, clinical decision support (CDS) and performance measurement represent distinct approaches to organizational change, yet these two organizational processes are interrelated. We set out to better understand how the relationship between the two is perceived, as well as how they jointly influence clinical practice. To understan...

Implementation of computerized clinical decision support (CDS), and its integration into workflow has not reached its potential. To better understand the use of CDS for colorectal cancer (CRC) screening at benchmark institutions for health information technology (HIT), we conducted direct observation, including opportunistic interviews of primary c...

This paper is a report of a study conducted to refine, shorten and validate the Healthcare Team Vitality Instrument. The Healthcare Team Vitality Instrument was developed to assess team vitality of nurses as well as other licensed and unlicensed personnel working as part of healthcare teams in inpatient hospital units. This instrument was necessary...

The effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing...

Objective: To facilitate patient handoffs between physicians, the computerized patient handoff tool (PHT) extracts information from the electronic health record to populate a form that is printed and given to the cross-cover physician. Objectives were to: (1) evaluate the rate at which data elements of interest were extracted from the electronic he...

Using data from a biracial community sample of adolescents, the present study examined trajectories of alcohol use and abuse over a 15-year period, from adolescence into young adulthood, as well as the extent to which these trajectories were differentially predicted by coping and enhancement motives for alcohol use among the 2 groups. Coping and en...

The widespread gap between evidence and practice for clinical and preventive services argues for a deeper understanding of effective quality improvement (QI) and system change. Using implementation and system redesign sciences, we have developed and used an effective strategy to enable robust implementation of QI initiatives, including clinical pra...

We sought to analyze the self-reported hospitalization, emergency department visits, and outpatient visits of Persian Gulf War (deployed; n=1896) and Persian Gulf War-era (nondeployed; n=1799) military personnel 5 years postconflict to determine whether these groups had different rates of health care use. Compared with personnel who had not been de...

The rapid spread of antimicrobial resistance (AMR) in the US hospitals poses serious quality and safety problems. Expert panels, identifying strategies for optimizing antibiotic use and preventing AMR spread, have recommended hospitals undertake efforts to implement specific evidence-based practices. To develop and validate a measurement scale for...

Computerized clinical reminders (CCR) are useful tools for alerting healthcare providers of upcoming or overdue medical labs, procedures, or exams, possible drug-drug interactions, and actions to take to support adherence to relevant clinical-practice guidelines. CCR have been effective in improving preventive service delivery, and have positively...

Background: Whether to perform active surveillance cultures (ASC) for methicillin-resistant Staphylococcus aureus (MRSA) in hospitalized patients is an important and controversial question. Many, but not all, single-institution studies have demonstrated benefit. However, start-up costs are high. Thus, we decided to study this question further using...

Three experimental studies, one correlational study, and a meta-analysis tested key hypotheses concerning the short-term and long-term impact of exposure to violent video games. Experiment 1 found that violent video games in general increase the accessibility of aggressive thoughts. Experiments 2 and 3 found that playing violent video games increas...

It is observed that hot weather and violence go hand in hand. This fact can be derived from a variety of sources, from a variety of centuries, and from a variety of continents. The first major review of the empirical literature on temperature effects on aggression relied on two epistemological strategies—namely, triangulation and meta-analysis. How...