St Lukes Episcopal Health System

United States

St Lukes Episcopal Health System

United States
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Lopez-Olivo M.A.,University of Houston | Landon G.C.,St Lukes Episcopal Health System | Siff S.J.,St Lukes Episcopal Health System | Edelstein D.,St Lukes Episcopal Health System | And 7 more authors.
Annals of the Rheumatic Diseases | Year: 2011

Objective: To identify potential psychosocial and educational barriers to clinical success following knee replacement. Patients and Methods: The authors evaluated 241 patients undergoing total knee replacement, preoperatively and 6 months after surgery. Outcomes included the Western Ontario McMaster (WOMAC) scale and the Knee Society rating system (KSRS). Independent variables included: the medical outcome study-social support scale; depression, anxiety and stress scale; brief COPE inventory; health locus of control; arthritis self-effi cacy scale and the life orientation test-revised. Multiple regression models evaluated associations of baseline demographic and psychosocial variables with outcomes at 6 months, controlling for body mass index, comorbidities and baseline outcome scores. Results: Patients' mean age was 65±9 years; 65% were women. Most patients improved outcomes after surgery. Several psychosocial variables were associated with outcomes. Regression analyses indicated lower education, less tangible support, depression, less problem-solving coping, more dysfunctional coping, lower internal locus of control were associated with worse WOMAC scores (R2 contribution of psychosocial variables for pain 0.07; for function, 0.14). Older age, lower education, depression and less problem-solving coping were associated with poorer total KSRS scores (R 2 contribution of psychosocial variables to total KSRS model 0.09). Psychosocial variables as a set contributed from 25% to 74% of total explained variance across the models tested. Conclusion: Patients' level of education, tangible support, depression, problem-solving coping, dysfunctional coping and internal locus of control were associated with pain and functional outcomes after knee replacement. The findings suggest that, in addition to medical management, perioperative psychosocial evaluation and intervention are crucial in enhancing knee replacement outcomes.


Singh J.A.,University of Alabama at Birmingham | Singh J.A.,The Surgical Center | Singh J.A.,Mayo Medical School | Luo R.,University of Texas M. D. Anderson Cancer Center | And 2 more authors.
Journal of Rheumatology | Year: 2014

Objective. To assess the reliability and clinically meaningful thresholds of intermittent and constant osteoarthritis pain (ICOAP) score, the Knee injury and Osteoarthritis Outcome Score Physical function Short-form (KOOS-PS), the Hip disability and Osteoarthritis Outcome Score Physical function Short-form (HOOS-PS), and the Quality of life subscales of HOOS/KOOS (HOOS-QOL/KOOS-QOL) in patients with knee or hip arthritis. Methods. One hundred and ninety-five patients (141 knee, 54 hip) seen at 2 orthopedic outpatient clinics with a diagnosis of knee or hip OA completed patient-reported questionnaires (ICOAP pain scale, KOOS-PS, HOOS-PS, KOOS-QOL, HOOS-QOL) at baseline and 2-week followup. Reliability was assessed using intraclass correlation coefficients (ICC). We calculated minimum clinically important difference (MCID) and moderate improvement in the subgroup that reported change in the status of their affected joint. Results. The reliability as assessed by ICC was as follows: ICOAP pain scale, 0.63 (0.48, 0.74) in patients with knee arthritis, and 0.86 (0.73, 0.93) for hip arthritis; KOOS-PS, 0.66 (0.52, 0.77); HOOS-PS, 0.82 (0.66, 0.91); KOOS-QOL, 0.79 (0.69, 0.86); and HOOS-QOL, 0.67 (0.42, 0.83). MCID and moderate improvement estimates in patients with knee arthritis were ICOAP pain scale, 18.5 and 26.7; KOOS-PS, 2.2 and 15.0; and KOOS-QOL, 8.0 and 15.6. A smaller sample in patients with hip arthritis precluded MCID and moderate improvement estimates. Conclusion. We found that ICOAP pain and KOOS-PS/HOOS-PS scales were reasonably reliable in patients with hip OA. Reliability of these scales was much lower in patients with knee arthritis. Thresholds for clinically meaningful change in pain or function on these scales were estimated for patients with knee arthritis. The Journal of Rheumatology Copyright © 2014. All rights reserved.


Hysong S.J.,Michael bakey Veterans Affairs Medical Center | Hysong S.J.,Baylor College of Medicine | Esquivel A.,St Lukes Episcopal Health System | Sittig D.F.,University of Houston | And 6 more authors.
Implementation Science | Year: 2011

Background: 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 andamp; 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.Methods: 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.Results: 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.Conclusions: 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. andcopy; 2011 Hysong et al; licensee BioMed Central Ltd.


Hysong S.J.,Baylor College of Medicine | Sawhney M.K.,Baylor College of Medicine | Wilson L.,Baylor College of Medicine | Sittig D.F.,University of Houston | And 3 more authors.
BMC Medical Informatics and Decision Making | Year: 2011

Background: Notifying clinicians about abnormal test results through electronic health record (EHR) -based "alert" notifications may not always lead to timely follow-up of patients. We sought to understand barriers, facilitators, and potential interventions for safe and effective management of abnormal test result delivery via electronic alerts. Methods. We conducted a qualitative study consisting of six 6-8 member focus groups (N = 44) at two large, geographically dispersed Veterans Affairs facilities. Participants included full-time primary care providers, and personnel representing diagnostic services (radiology, laboratory) and information technology. We asked participants to discuss barriers, facilitators, and suggestions for improving timely management and follow-up of abnormal test result notifications and encouraged them to consider technological issues, as well as broader, human-factor-related aspects of EHR use such as organizational, personnel, and workflow. Results: Providers reported receiving a large number of alerts containing information unrelated to abnormal test results, many of which were believed to be unnecessary. Some providers also reported lacking proficiency in use of certain EHR features that would enable them to manage alerts more efficiently. Suggestions for improvement included improving display and tracking processes for critical alerts in the EHR, redesigning clinical workflow, and streamlining policies and procedures related to test result notification. Conclusion: Providers perceive several challenges for fail-safe electronic communication and tracking of abnormal test results. A multi-dimensional approach that addresses technology as well as the many non-technological factors we elicited is essential to design interventions to reduce missed test results in EHRs. © 2011 Hysong et al; licensee BioMed Central Ltd.


Waimann C.A.,Hospital Dr Hector Cura | Fernandez-Mazarambroz R.J.,University of Houston | Cantor S.B.,University of Houston | Lopez-Olivo M.A.,University of Houston | And 4 more authors.
Arthritis Care and Research | Year: 2014

Objective Total knee replacement (TKR) rates have significantly increased in the past decade. While the procedure itself might be costly, the cost-effectiveness and potential offset costs from patient and societal benefits have not been clearly established. The objective of this study was to perform an economic evaluation of TKR in patients with knee osteoarthritis (OA). Methods We conducted a 6-month prospective cohort study of 212 patients with knee OA who underwent TKR at a single hospital in Houston, Texas. We included patient-level data from hospital billing databases and the patients' self-reported direct and indirect costs. The clinical outcome measure was pain and function measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire; we used the minimum clinically important difference (MCID; ≥20-point change) and the WOMAC 20% (WOMAC20), 50% (WOMAC50), and 70% (WOMAC70) relative improvement criteria. Incremental cost-effectiveness ratios were estimated using direct and indirect costs and WOMAC improvement. A societal perspective was used and multiple sensitivity analyses were performed to assess the robustness of the principal analysis. Results The total incremental cost per TKR was 20,133. The incremental cost-effectiveness ratios (ICERs) for improvement at 6 months were 33,345, 25,255, 35,274, and 56,908 for the MCID, WOMAC20, WOMAC50, and WOMAC70, respectively. Best- and worst-case scenario sensitivity analyses did not have a significant impact on the ICERs. Patient time lost was the most influential variable in the multiway sensitivity analysis. Conclusion TKR is an effective intervention in reducing pain and improving functional status among patients with knee OA and is cost effective at both low and high levels of improvement. Copyright © 2014 by the American College of Rheumatology.


Sittig D.F.,University of Houston | Gonzalez D.,St Lukes Episcopal Health System | Singh H.,Baylor College of Medicine
International Journal of Medical Informatics | Year: 2014

Background: Reliable health information technology (HIT) in general, and electronic health record systems (EHRs) in particular are essential to a high-performing healthcare system. When the availability of EHRs are disrupted, alternative methods must be used to maintain the continuity of healthcare. Methods: We developed a survey to assess institutional practices to handle situations when EHRs were unavailable for use (downtime preparedness). We used literature reviews and expert opinion to develop items that assessed the implementation of potentially useful practices. We administered the survey to U.S.-based healthcare institutions that were members of a professional organization that focused on collaboration and sharing of HIT-related best practices among its members. All members were large integrated health systems. Results: We received responses from 50 of the 59 (84%) member institutions. Nearly all (96%) institutions reported at least one unplanned downtime (of any length) in the last 3 years and 70% had at least one unplanned downtime greater than 8. h in the last 3 years. Three institutions reported that one or more patients were injured as a result of either a planned or unplanned downtime. The majority of institutions (70-85%) had implemented a portion of the useful practices we identified, but very few practices were followed by all organizations. Conclusions: Unexpected downtimes related to EHRs appear to be fairly common among institutions in our survey. Most institutions had only partially implemented comprehensive contingency plans to maintain safe and effective healthcare during unexpected EHRs downtimes. © 2014 Elsevier Ireland Ltd.


Smith M.W.,Baylor College of Medicine | Murphy D.,Baylor College of Medicine | Laxmisan A.,Baylor College of Medicine | Sittig D.,University of Houston | And 3 more authors.
Applied Clinical Informatics | Year: 2013

Background: Abnormal test results do not always receive timely follow-up, even when providers are notified through electronic health record (EHR)-based alerts. High workload, alert fatigue, and other demands on attention disrupt a provider's prospective memory for tasks required to initiate follow-up. Thus, EHR-based tracking and reminding functionalities are needed to improve followup. Objectives: The purpose of this study was to develop a decision-support software prototype enabling individual and system-wide tracking of abnormal test result alerts lacking follow-up, and to conduct formative evaluations, including usability testing. Methods: We developed a working prototype software system, the Alert Watch And Response Engine (AWARE), to detect abnormal test result alerts lacking documented follow-up, and to present context-specific reminders to providers. Development and testing took place within the VA's EHR and focused on four cancer-related abnormal test results. Design concepts emphasized mitigating the effects of high workload and alert fatigue while being minimally intrusive. We conducted a multifaceted formative evaluation of the software, addressing fit within the larger socio-technical system. Evaluations included usability testing with the prototype and interview questions about organizational and workflow factors. Participants included 23 physicians, 9 clinical information technology specialists, and 8 quality/safety managers. Results: Evaluation results indicated that our software prototype fit within the technical environment and clinical workflow, and physicians were able to use it successfully. Quality/safety managers reported that the tool would be useful in future quality assurance activities to detect patients who lack documented follow-up. Additionally, we successfully installed the software on the local facility's "test" EHR system, thus demonstrating technical compatibility. Conclusion: To address the factors involved in missed test results, we developed a software prototype to account for technical, usability, organizational, and workflow needs. Our evaluation has shown the feasibility of the prototype as a means of facilitating better follow-up for cancer-related abnormal test results. © Schattauer 2013.


Esquivel A.,St Lukes Episcopal Health System | Sittig D.F.,University of Houston | Murphy D.R.,Baylor College of Medicine | Singh H.,Baylor College of Medicine
BMC Medical Informatics and Decision Making | Year: 2012

Electronic health records are increasingly being used to facilitate referral communication in the outpatient setting. However, despite support by technology, referral communication between primary care providers and specialists is often unsatisfactory and is unable to eliminate care delays. This may be in part due to lack of attention to how information and communication technology fits within the social environment of health care. Making electronic referral communication effective requires a multifaceted "socio- technical" approach. Using an 8-dimensional socio-technical model for health information technology as a framework, we describe ten recommendations that represent good clinical practices to design, develop, implement, improve, and monitor electronic referral communication in the outpatient setting. These recommendations were developed on the basis of our previous work, current literature, sound clinical practice, and a systems-based approach to understanding and implementing health information technology solutions. Recommendations are relevant to system designers, practicing clinicians, and other stakeholders considering use of electronic health records to support referral communication. © 2012 Esquivel et al.; licensee BioMed Central Ltd.


Vallejo B.C.,St Lukes Episcopal Health System
Hospital topics | Year: 2012

Improving healthcare in the 21st century will depend on how well vast amounts of data are mined. However, converting data contained in multiple hospital and clinical databases into information that can be used for clinical decision support is a complex task. The process involves a combination of cultural and technological steps that are time-consuming and resource-intensive. The authors describe one hospital's long journey toward becoming a data-driven organization.


Vallejo B.C.,St Lukes Episcopal Health System | Flies L.A.,St Lukes Episcopal Health System | Fine D.J.,St Lukes Episcopal Health System
Journal of Clinical Engineering | Year: 2011

Hospital accreditation has been widely used to promote accountability for patient safety and quality in healthcare and is required for reimbursement by the Centers for Medicare & Medicaid Services. From 1965 when the Medicare law was enacted, until 2008, The Joint Commission and the American Osteopathic Association's Healthcare Facilities Accreditation Program were the only approved hospital accrediting bodies available to hospitals in the United States. In 2008, Det Norske Veritas Healthcare, Inc was granted similar authority to determine whether a hospital meets Centers for Medicare & Medicaid Services requirements. This article compares the advantages and disadvantages offered by the 3 organizations. Copyright © 2010 Lippincott Williams & Wilkins.

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