Data Visualization of Home Care Admission Nurses' Decision-Making

Data Visualization of Home Care Admission Nurses' Decision-Making • Innovative Applications in Data Visualization S38 Paulina Sockolow DrPH MS MBA Drexel University Twitter: #AMIA2017

Disclosure • I have no relevant relationships with commercial interests to disclose. AMIA 2017 | amia.org

Learning Objectives • After participating in this session the learner should be better able to: • Describe the benefits of using a node-link diagram visualization • Explain the analytic step to prepare data for display in a node-link diagram visualization • List some display characteristics of the node-link diagram visualization AMIA 2017 | amia.org

Data Visualization of Home Care Admission Nurses' Decision-Making Paulina S SockolowDrPH MS MBA1, YushiYang PhD2, Ellen J. Bass PhD1,2, Kathryn H Bowles RN PhD3,4, Annika Holmberg BSN RN3, Sheryl PotashnikPhD1 1Drexel University, College of Nursing and Health Professions, Philadelphia PA; 2Drexel University, College of Computing and Informatics; 3University of Pennsylvania School of Nursing, Philadelphia, PA; 4Visiting Nurse Service of New York

Why Study Home Care Admissions? • Home health agencies admit 11 million patients per year to home care • Home care services include skilled nursing, therapies, social work • Homebound patients • Clinicians operate independently in the home under physician orders • Home care agency challenges • Timely & accurate data collection during admission • 30% homecare patients re-hospitalized within 60 days of hospital discharge • We may reduce re-hospitalization rate with better information • Enhanced • Care planning • Allocation of clinical care services pss44@drexel.edu

Why Conduct an Informatics Study? • Health information technology (HIT) can • Support admission process • Improve quality of care • Contextual factors challenge HIT implementation, adoption • To better understand admitting nurses’ information needs pss44@drexel.edu 11/2017

Hospital Discharge to Home Care Discharge Separate electronic health records pss44@drexel.edu 11/2017

Objective • We conducted a focus group of home care nurses asking about: tasks, information needs, and 4 decisions during the admission process • Findings will be integrated with those from observational studies & case reviews (in progress) to • Develop recommendations to enhance the home care admission process • Inform HIT standards for home health agency electronic health records (EHR) • We introduce methods to • Support analysts who seek to understand how nurses make decisions in relation to the information and tasks • Facilitate communication of findings to stakeholders when time is precious • Home health agency nurses • Other subject matter experts • We developed a custom node-link diagram visualization pss44@drexel.edu

Focus Group: Four Main Clinical Decisions • Medication reconciliation • Create accurate list of medications that patient should take • Compare that list against physician's discharge orders & medications in the home • Plan of care: • Orders for assessment, education, and performance • For problems the nurse has decided need to be addressed in care episode • Visit timing and frequency • Next skilled nursing visits following admission • Total number of follow-up visits • Inclusion of other disciplines (“Services”) in addition to skilled nursing • Additional agency services needed in the care plan • e.g., physical therapy, social work pss44@drexel.edu

Node-Link Diagram Visualization of Tasks, Information, Decisions • Node-link diagram sometimes called a network diagram • Nodes • Also called vertices • Represented as shapes with or without text labels • Links • Also called edges • Shows relationships among nodes • Represented as lines between nodes • Can be undirected showing association • Can be directed showing direction of relationship • Arrows typically displayed on links to indicate direction. pss44@drexel.edu

Methods: Setting • 1 home care agency • Rural, in Pennsylvania • Patients • Majority white population • Lower socio-economic status • EHR: • Widely used in rural agencies in the region • On laptop pss44@drexel.edu

Data collection • 75 minute focus group with 6 nurses who admit patients • Responses written on flip chart pages • Audio recordings of session • Instruments • Demographic data collection instrument • Open-ended focus group questions about the start of care visit: • What tasks they needed to complete for each of the clinical decisions • Whether the task generated information they needed for the related clinical decision pss44@drexel.edu

Data Analysis • Data Visualization • Identified features to be represented • Nodes • Links • Themes • Identified nodes and links using thematic analysis • Display data visualization using Lucidchart (Lucid Software) • Display nodes & links • Add annotations for themes • Modified images to improve readability • Thematic content analysis • Coding • Developed codebook • Multiple coders: 80% inter-rater reliability • NVivosoftware to organize themes • Research team grouped themes pss44@drexel.edu

Results pss44@drexel.edu

Visualization Features Nodes are organized by type (decision, task, and information) and categories are color coded Decisions made during start of care Information to make each decision Tasks completed to make decision pss44@drexel.edu

Visualization Features Links represent associations between nodes Association between tasks and decisions Association between tasks and information Direction links indicate information generation or use pss44@drexel.edu

Visualization Features Triangles indicate that information themes can be decomposed into sub-themes Node side height indicates the number of links Number of decisions associated with each task Number of information themes associated with each task Number of tasks associated with an information element pss44@drexel.edu

Longer vertical sides indicate more links to tasks than other nodes 11 task nodes do not link to information nodes Patient theme has most number of tasks that generate information (purpose of admission: assess patient’s situation & needs to develop plan of care) Shorter height (nodes with few links): small set of information types associated with tasks Enhanced node-link diagram of four clinical decisions and start of care showing characterization of the relationships between tasks, information, and clinical decisions

Task node with most links to information types has longer right side The number indicates the total number of information sub-themes of an information theme Patient theme has most number of tasks that generate information Line style thickness indicate the number of shared information sub-themes for a task-information theme pair 5 task nodes do not link to information nodes Enhanced node-link diagram of plan of care clinical decision information: Example diagram to support analysis of a clinical decision pss44@drexel.edu

Expected task node to link to Home Environment information theme Information sub-themes Theme can be generated by multiple tasks Visualization ofvisit timing and frequency decision showing ability to drill down to information sub-themes pss44@drexel.edu

Discussion • The focus group data are presented with prototype visualizations to help answer a number of types of questions pss44@drexel.edu

Exploratory questions: Information emerges from node-link diagrams which analyst may not have noticed otherwise Example: information about home environment was sparse. - Highlights the need to ensure that nurse assumes that another clinician (e.g., occupational therapist) is responsible for surveying home environment pss44@drexel.edu

- Questions related to our interpretation of the data, and checking back with the subject matter experts to verify what the data suggest - Easier identification of patterns by viewer Example: Show the nurse the gap - lack of a link to Home Environment information theme - and ask nurse about it Caregiver theme appears only in this diagram Visualization ofvisit timing and frequency decision pss44@drexel.edu

Admission workflow questions: Show where the nurse was expending effort to do something that may better be achieved by another entity or process Example: diagrams indicate where nurse conducted many tasks (e.g., start of care, plan of care) which did not produce information needed for admission Example: nurse obtains eligibility criteria information (e.g., insurance coverage, homebound status) from the patient pss44@drexel.edu

Conclusion • Advantages of this visualization • Compared to other methods • (e.g., flow chart, information flow diagram, decision ladder) that respectively show detailed process information for an individual activity, how information is communicated, and decompositions of decision sequences and short cuts that can be taken in the process • The node-link diagram can be synergistic with those techniques and be helpful in answering other types of questions • High-level view of themes; relationships of clinical decisions, tasks, information • Enabled systematic understanding of decision-making process, i.e., how information is used (and not used) in multiple tasks and decisions • Detailed diagrams with information about sub-themes helped to highlight information used across tasks • Data visualization method useful in domains outside of healthcare • Have limited numbers of decisions, tasks, and information elements • For those seeking to map information-related decision-making pss44@drexel.edu

Acknowledgements • This project was supported by grant number R01HS024537 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality • Wei Quan for encoding earlier data visualizations • The home care agency and the participants • The anonymous reviewers who encouraged the authors to improve upon the originally submitted data visualizations pss44@drexel.edu

Thank you

Results • Focus group nurses • Roles • RNs • Care managers • Demographics • White • Young: median age of 32 years • Majority female • Experience • EHRs: median of 3 years • Health care: median of 6 years

Thematic analysis: 28 Tasks Distributed Among the Clinical Decisions

7 Themes of Information Generated from Tasks to Make Clinical Decisions

future work • evaluate the efficacy of the visualizations in check backs with the home care agency • investigate the implementation of the design guidelines • usability • extending the set of features included • Develop additional representation guidelines • Links: e.g., line color, line style • Nodes: e.g., symbol shape to represent additional features

Discussion • Focus group case study executed to identify the relationships between admission nurses’ decisions, tasks, and information gathering and use • Enhanced node-link diagram concept developed to represent the qualitative findings from the focus group • The concept was informed by collaboration between experts in the clinical decision making process and human factors professionals • We introduced the features in the enhanced node-link diagram and presented visualization guidelines for how to instantiate each feature in order to highlight findings considered significant by clinical experts • The focus group data are presented with prototype visualizations that meet the guidelines • Visualizations help to answer a number of types of questions

Question About Methods Used for Data Collection • Did our method provide a consistent set of information: member checking needed? • Numerous tasks and the sparse Services diagram indicate that the 75-minute data collection may not have been enough time • Suggest where the gaps in data are, so that during the next data collection the team can probe further pss44@drexel.edu

Data Visualization of Home Care Admission Nurses' Decision-Making