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Virtual-first care: Opportunities and challenges for the future of diagnostic reasoning

Lawrence, Katharine; Mann, Devin
SCOPUS:85182482557
ISSN: 1743-4971
CID: 5629652

Potential bias and lack of generalizability in electronic health record data: reflections on health equity from the National Institutes of Health Pragmatic Trials Collaboratory

Boyd, Andrew D; Gonzalez-Guarda, Rosa; Lawrence, Katharine; Patil, Crystal L; Ezenwa, Miriam O; O'Brien, Emily C; Paek, Hyung; Braciszewski, Jordan M; Adeyemi, Oluwaseun; Cuthel, Allison M; Darby, Juanita E; Zigler, Christina K; Ho, P Michael; Faurot, Keturah R; Staman, Karen L; Leigh, Jonathan W; Dailey, Dana L; Cheville, Andrea; Del Fiol, Guilherme; Knisely, Mitchell R; Grudzen, Corita R; Marsolo, Keith; Richesson, Rachel L; Schlaeger, Judith M
Embedded pragmatic clinical trials (ePCTs) play a vital role in addressing current population health problems, and their use of electronic health record (EHR) systems promises efficiencies that will increase the speed and volume of relevant and generalizable research. However, as the number of ePCTs using EHR-derived data grows, so does the risk that research will become more vulnerable to biases due to differences in data capture and access to care for different subsets of the population, thereby propagating inequities in health and the healthcare system. We identify 3 challenges-incomplete and variable capture of data on social determinants of health, lack of representation of vulnerable populations that do not access or receive treatment, and data loss due to variable use of technology-that exacerbate bias when working with EHR data and offer recommendations and examples of ways to actively mitigate bias.
PMID: 37364017
ISSN: 1527-974x
CID: 5540142

Equity and bias in electronic health records data

Boyd, Andrew D; Gonzalez-Guarda, Rosa; Lawrence, Katharine; Patil, Crystal L; Ezenwa, Miriam O; O'Brien, Emily C; Paek, Hyung; Braciszewski, Jordan M; Adeyemi, Oluwaseun; Cuthel, Allison M; Darby, Juanita E; Zigler, Christina K; Ho, P Michael; Faurot, Keturah R; Staman, Karen; Leigh, Jonathan W; Dailey, Dana L; Cheville, Andrea; Del Fiol, Guilherme; Knisely, Mitchell R; Marsolo, Keith; Richesson, Rachel L; Schlaeger, Judith M
Embedded pragmatic clinical trials (ePCTs) are conducted during routine clinical care and have the potential to increase knowledge about the effectiveness of interventions under real world conditions. However, many pragmatic trials rely on data from the electronic health record (EHR) data, which are subject to bias from incomplete data, poor data quality, lack of representation from people who are medically underserved, and implicit bias in EHR design. This commentary examines how the use of EHR data might exacerbate bias and potentially increase health inequities. We offer recommendations for how to increase generalizability of ePCT results and begin to mitigate bias to promote health equity.
PMCID:10330606
PMID: 37225122
ISSN: 1559-2030
CID: 5536592

Digital Minimalism - An Rx for Clinician Burnout

Singh, Nina; Lawrence, Katharine; Sinsky, Christine; Mann, Devin M
PMID: 36971285
ISSN: 1533-4406
CID: 5463082

Association Between Types of Family Support and Glycemic Control for Adults With Cognitive Impairment

Zheng, Yaguang; Lawrence, Katharine; Fletcher, Jason; Qi, Xiang; Wu, Bei
Background: Family support is important in assisting with diabetes self-management for individuals with cognitive impairment, but what types of family support are most effective remain unknown. Objectives: We aimed to examine the association between the types of family support in diabetes self-management with glycemic control in middle-aged and older adults with cognitive impairment. Methods: A total of 267 individuals were included with diabetes and cognitive impairment (27-point Telephone Interview for Cognitive Status score <12), using the data of 2003 Health and Retirement Study (HRS) Diabetes Study and 2004 wave of the HRS. Results: Most respondents were White (68.9%), followed by Black (25.8%). The mean age was 73.4±8.4 years. Adults with strong family support (as indicated by a "strongly agree" response) in testing sugar and in handling feelings about diabetes had significantly lower A1C compared with those with less family support (mean ± standard deviation: 7.08±1.39 vs. 7.51±1.42, P=.03; 6.79±0.87 vs. 7.57±1.53; P=.007 respectively). Conclusions: Our findings indicate that family members of individuals with cognitive impairment provide critical support to patients with diabetes and cognitive impairment, and may need additional intervention to assist with diabetes self-management tasks that require unique knowledge and skills.
SCOPUS:85180731854
ISSN: 2333-7214
CID: 5631192

Operational Implementation of Remote Patient Monitoring Within a Large Ambulatory Health System: Multimethod Qualitative Case Study

Lawrence, Katharine; Singh, Nina; Jonassen, Zoe; Groom, Lisa L.; Arias, Veronica Alfaro; Mandal, Soumik; Schoenthaler, Antoinette; Mann, Devin; Nov, Oded; Dove, Graham
Background: Remote patient monitoring (RPM) technologies can support patients living with chronic conditions through self-monitoring of physiological measures and enhance clinicians"™ diagnostic and treatment decisions. However, to date, large-scale pragmatic RPM implementation within health systems has been limited, and understanding of the impacts of RPM technologies on clinical workflows and care experience is lacking. Objective: In this study, we evaluate the early implementation of operational RPM initiatives for chronic disease management within the ambulatory network of an academic medical center in New York City, focusing on the experiences of "early adopter" clinicians and patients. Methods: Using a multimethod qualitative approach, we conducted (1) interviews with 13 clinicians across 9 specialties considered as early adopters and supporters of RPM and (2) speculative design sessions exploring the future of RPM in clinical care with 21 patients and patient representatives, to better understand experiences, preferences, and expectations of pragmatic RPM use for health care delivery. Results: We identified themes relevant to RPM implementation within the following areas: (1) data collection and practices, including impacts of taking real-world measures and issues of data sharing, security, and privacy; (2) proactive and preventive care, including proactive and preventive monitoring, and proactive interventions and support; and (3) health disparities and equity, including tailored and flexible care and implicit bias. We also identified evidence for mitigation and support to address challenges in each of these areas. Conclusions: This study highlights the unique contexts, perceptions, and challenges regarding the deployment of RPM in clinical practice, including its potential implications for clinical workflows and work experiences. Based on these findings, we offer implementation and design recommendations for health systems interested in deploying RPM-enabled health care.
SCOPUS:85167504576
ISSN: 2292-9495
CID: 5619692

Association Between Types of Family Support and Glycemic Control for Adults With Cognitive Impairment

Zheng, Yaguang; Lawrence, Katharine; Fletcher, Jason; Qi, Xiang; Wu, Bei
BACKGROUND/UNASSIGNED:Family support is important in assisting with diabetes self-management for individuals with cognitive impairment, but what types of family support are most effective remain unknown. OBJECTIVES/UNASSIGNED:We aimed to examine the association between the types of family support in diabetes self-management with glycemic control in middle-aged and older adults with cognitive impairment. METHODS/UNASSIGNED:A total of 267 individuals were included with diabetes and cognitive impairment (27-point Telephone Interview for Cognitive Status score <12), using the data of 2003 Health and Retirement Study (HRS) Diabetes Study and 2004 wave of the HRS. RESULTS/UNASSIGNED:=.007 respectively). CONCLUSIONS/UNASSIGNED:Our findings indicate that family members of individuals with cognitive impairment provide critical support to patients with diabetes and cognitive impairment, and may need additional intervention to assist with diabetes self-management tasks that require unique knowledge and skills.
PMCID:10748626
PMID: 38143875
ISSN: 2333-7214
CID: 5623442

Evidence for telemedicine's ongoing transformation of healthcare delivery since the onset of COVID-19: A retrospective observational study

Mandal, Soumik; Wiesenfeld, Batia; Mann, Devin; Lawrence, Katharine; Chunara, Rumi; Testa, Paul; Nov, Oded
BACKGROUND:The surge of telemedicine use during the early stages of the coronavirus-19 (COVID-19) pandemic has been well documented. However, scarce evidence considers the utilization of telemedicine in the subsequent period. OBJECTIVE:This study aims to evaluate utilization patterns of video-based telemedicine visits for ambulatory care and urgent care provision over the course of recurring pandemic waves in one large health system in New York City, and what this means for healthcare delivery. METHODS:Retrospective electronic health record (EHR) data of patients between January 1st, 2020, and February 28th, 2022 were used to longitudinally track and analyze telemedicine and in-person visit volumes across ambulatory care specialties and urgent care, as well as compare them to a pre-pandemic baseline (June to November 2019). Diagnosis codes to differentiate COVID-19 suspected visits from non-COVID-19 visits, as well as evaluating COVID-19 based telemedicine utilization over time, were compared to the total number of COVID-19 positive cases in the same geographic region (city-level). The time-series data was segmented based on change-point analysis and variances in visit trends were compared between the segments. RESULTS:The emergence of COVID-19 prompted an early increase in the number of telemedicine visits across the urgent care and ambulatory care settings. This utilization continued throughout the pandemic at a much higher level than the pre-pandemic baseline for both COVID-19 and non-COVID suspected visits, despite fluctuation in COVID-19 cases throughout the pandemic and the resumption of in-person clinical services. Utilization of telemedicine-based urgent care services for COVID-19 suspected visits showed more variance in response to each pandemic wave, but telemedicine visits for ambulatory care have remained relatively steady after the initial crisis period. During the Omicron wave, the utilization of all visit types including in-person activities decreased. Patients between 25 and 34 years of age were the largest users of telemedicine-based urgent care. Patient satisfaction with telemedicine-based urgent care remained high despite the rapid scaling of services to meet increased demand. CONCLUSIONS:The trend of increased use of telemedicine as a means of healthcare delivery relative to the pre-COVID-19 baseline has been maintained throughout the later pandemic periods despite fluctuating COVID-19 cases and the resumption of in-person care delivery. Overall satisfaction with telemedicine-based care is also high. The trends in telemedicine utilization suggest that telemedicine-based healthcare delivery has become a mainstream and sustained supplement to in-person-based ambulatory care, particularly for younger patients, for both urgent and non-urgent care needs. These findings have implications for the healthcare delivery system, including practice leaders, insurers, and policymakers. Further investigation is needed to evaluate telemedicine adoption by key demographics, identify ongoing barriers to adoption, and explore the impacts of sustained use of telemedicine on healthcare outcomes and experience.
PMID: 36103553
ISSN: 2561-326x
CID: 5336262

A framework for digital health equity

Richardson, Safiya; Lawrence, Katharine; Schoenthaler, Antoinette M; Mann, Devin
We present a comprehensive Framework for Digital Health Equity, detailing key digital determinants of health (DDoH), to support the work of digital health tool creators in industry, health systems operations, and academia. The rapid digitization of healthcare may widen health disparities if solutions are not developed with these determinants in mind. Our framework builds on the leading health disparities framework, incorporating a digital environment domain. We examine DDoHs at the individual, interpersonal, community, and societal levels, discuss the importance of a root cause, multi-level approach, and offer a pragmatic case study that applies our framework.
PMCID:9387425
PMID: 35982146
ISSN: 2398-6352
CID: 5300232

The Impact of Telemedicine on Physicians' After-hours Electronic Health Record "Work Outside Work" During the COVID-19 Pandemic: Retrospective Cohort Study

Lawrence, Katharine; Nov, Oded; Mann, Devin; Mandal, Soumik; Iturrate, Eduardo; Wiesenfeld, Batia
BACKGROUND:Telemedicine as a mode of health care work has grown dramatically during the COVID-19 pandemic; the impact of this transition on clinicians' after-hours electronic health record (EHR)-based clinical and administrative work is unclear. OBJECTIVE:This study assesses the impact of the transition to telemedicine during the COVID-19 pandemic on physicians' EHR-based after-hours workload (ie, "work outside work") at a large academic medical center in New York City. METHODS:We conducted an EHR-based retrospective cohort study of ambulatory care physicians providing telemedicine services before the pandemic, during the acute pandemic, and after the acute pandemic, relating EHR-based after-hours work to telemedicine intensity (ie, percentage of care provided via telemedicine) and clinical load (ie, patient load per provider). RESULTS:A total of 2129 physicians were included in this study. During the acute pandemic, the volume of care provided via telemedicine significantly increased for all physicians, whereas patient volume decreased. When normalized by clinical load (ie, average appointments per day by average clinical days per week), telemedicine intensity was positively associated with work outside work across time periods. This association was strongest after the acute pandemic. CONCLUSIONS:Taking physicians' clinical load into account, physicians who devoted a higher proportion of their clinical time to telemedicine throughout various stages of the pandemic engaged in higher levels of EHR-based after-hours work compared to those who used telemedicine less intensively. This suggests that telemedicine, as currently delivered, may be less efficient than in-person-based care and may increase the after-hours work burden of physicians.
PMCID:9337620
PMID: 35749661
ISSN: 2291-9694
CID: 5282312