Application of the Consolidated Framework for Implementation Research Model to Design and Implement an Optimization Methodology within an Ambulatory Setting

Abstract

Background Following the implementation of a new electronic health record (EHR) system at Columbia University Irving Medical Center (CUIMC), the demands of the novel coronavirus disease 2019 (COVID-19) pandemic forced an abrupt reallocation of resources away from EHR adoption. To assist staff in focusing on techniques for improving EHR utilization, an optimization methodology was designed referencing the Consolidated Framework for Implementation Research (CFIR) approach. Methods The study was performed using a methodology that comprised of two primary components as follows: (1) analysis of qualitative and quantitative data and (2) participation of frontline staff in project work groups. Working groups mapped out the current state of the identified workflows, designed and implemented interventions, monitored the effectiveness of each intervention, and scaled the proposed changes. Results As a result of the optimization methodology, clinical and operational workflows improved in the pilot department. Operationally, the pilot department increased enrollment of patients in the virtual patient portal by 20%, increased schedule utilization by 25%, and reduced average check-in time by 19%. Clinically, the pilot department had a statistically significant increase in dictation and NoteWriter tool note composition from their baseline month to their observed month. Compared with the control department, the pilot department had a statistically significant increase in SmartTool and dictation note composition. The control department showed smaller increases, and in some cases a decline in performance, in these areas of operational and clinical workflows. Conclusion The CFIR framework helped design an optimization methodology by applying a set of constructs to support effective organizational optimization, accounting for inner and outer settings. Through this methodology, the inner setting was supported in leading the identification and execution of interventions targeted to impact the outer setting. The phase-1 data at CUIMC suggest this strategy is effective in identifying opportunities, implementing interventions and creating a scalable process for continued organizational optimization.

The Role of Human and Organizational Factors in the Pursuit of One Digital Health

“…We also need to appreciate that while HIT may be designed for a certain purpose, it may need to be adapted to move from supporting micro level behaviours such as efficiency to macro level outcomes such as safety [25]. We must get into a mindset for digital health design that considers the broader ecosystem where digital health is used such as supporting regional interoperability at the macro level and specialty-specific views of data to support multi-organizational clinical services at the micro level [35,39,44,50].…”

The State-of-the-Art of Patient Portals: Adapting to External Factors, Addressing Barriers, and Innovating

“…New care processes and workflow changes involving many different stakeholders were needed to successfully transition to telehealth, including changes to scheduling, the additional preparations needed prior to virtual visits (e.g., patient portal enrollment, virtual processes for previsit questionnaires), conversion of in-person processes to the virtual context (e.g., "rooming"), and postvisit follow-up, [47][48][49][50][51][52][53] as well as increased remote disease monitoring and virtual patient education programs. 54 To achieve these changes, HCOs also needed to employ implementation strategies to encourage acceptance among the various stakeholders.…”

“…We found that existing literature was more likely to describe health care professional-facing implementation strategies to encourage acceptance of virtual visits than patient- • New virtual care processes were required for all stages of a visit-previsit such as patient portal enrollment, during such as "rooming," and postvisit follow-up-as well as remote disease monitoring and patient education. [47][48][49][50][51][52][53][54] • The literature describes a wide variety of clinician-facing, sociotechnical implementation strategies, including securing and organizing human resources (e.g., clinician champions); developing guidelines, standard scripts, and best practices; offering trainings and clearly communicating evolving processes and resources; and leveraging technological resources. [47][48][49][50][51][52][53]55 • The patient-facing initiatives reported in the literature are limited to technological training and support, with an emphasis on mitigating the risk of digital health disparities.…”

“…[47][48][49][50][51][52][53][54] • The literature describes a wide variety of clinician-facing, sociotechnical implementation strategies, including securing and organizing human resources (e.g., clinician champions); developing guidelines, standard scripts, and best practices; offering trainings and clearly communicating evolving processes and resources; and leveraging technological resources. [47][48][49][50][51][52][53]55 • The patient-facing initiatives reported in the literature are limited to technological training and support, with an emphasis on mitigating the risk of digital health disparities. [47][48][49][50]52,[55][56][57][58][59][60][61][62] Developing and deploying portal tools to respond to COVID-19…”

“…[47][48][49][50][51][52][53]55 • The patient-facing initiatives reported in the literature are limited to technological training and support, with an emphasis on mitigating the risk of digital health disparities. [47][48][49][50]52,[55][56][57][58][59][60][61][62] Developing and deploying portal tools to respond to COVID-19…”