One Hospital-Five Doors: A Model for Critical Access Hospital Sustainability.

Background: We wanted to assess whether a regional approach to bed management and staffing could improve financial sustainability without reducing services in rural communities.

Methods: Regional approaches to patient placement, hospital throughput, and staffing were coupled with enhanced services at 1 hub hospital and 4 critical access hospitals.

Results: We improved the use of patient beds in the 4 critical access hospitals, increased hub hospital capacity, and improved the health system's financial performance while maintaining or enhancing services at the critical access hospitals.

Collaborative Rooming: An Innovative Pilot Project to Overcome Primary Care Challenges.

Background: Primary care physicians are overburdened with growing complexities and increasing expectations for primary care visits. To meet expectations, primary care physicians must multitask during visits and spend extra hours in the office for charting, billing, and documentation. This impacts the physician's quality of life and may affect the quality of patient care.

Activating the Hospital Incident Command System Response in a Community Specialty Practice: The Mayo Clinic Experience.

Introduction: The COVID-19 pandemic presented health care organizations with a unique challenge in determining effective management of a large-scale incident across an extended time period.

Case Presentation: This report describes the response of a multisite integrated system to the COVID-19 pandemic through activation of the Hospital Incident Command System.

Discussion: A robust emergency response plan with multidisciplinary involvement can help to ensure clear lines of accountability and expedite decision-making.

Regional Specialty Surgical Practice Efficiencies Gained as a Result of COVID-19.

Objective: To identify opportunities for discontinuing elective and nonemergency surgical cases in a regional surgical practice in response to coronavirus disease 2019 (COVID-19).

Patients And Methods: COVID-19 began to affect surgical practices across the United States in March 2020. On March 17, 2020, all elective and nonemergency surgical care was deferred to prepare the Mayo Clinic Health System sites in northwestern Wisconsin for an anticipated surge in patients with COVID-19.

EHR Conversion on the PreOp Care: A Pre-Post Workflow Comparison.

The impact of EHRs conversion on clinicians' daily work is crucial to evaluate the success of the intervention for Hospitals and to yield valuable insights into quality improvement. To assess the impact of different EHR systems on the preoperative nursing workflow, we used a structured framework combining quantitative time and motion study and qualitative cognitive analysis to characterize, visualize and explain the differences before and after an EHR conversion. The results showed that the EHR conversion brought a significant decrease in the patient case time and a reduced percentage of time using EHR.

Study of EHR-mediated workflows using ethnography and process mining methods.

Rapid ethnography and data mining approaches have been used individually to study clinical workflows, but have seldom been used together to overcome the limitations inherent in either type of method. For rapid ethnography, how reliable are the findings drawn from small samples? For data mining, how accurate are the discoveries drawn from automatic analysis of big data, when compared with observable data? This paper explores the combined use of rapid ethnography and process mining, aka ethno-mining, to study and compare metrics of a typical clinical documentation task, vital signs charting. The task was performed with different electronic health records (EHRs) used in three different hospital sites.

The Development of a Daily Comprehensive and Multidisciplinary Health Care Leadership Huddle.

Introduction: Consistent and concise communication in a large health care organization that is geographically dispersed is a challenge. Issues often are not addressed with the appropriate individuals in the most timely and effective manner, which results in patient flow disruptions, service gaps, and provider and administrator frustration.

Case Presentation: This report describes the development of a daily leadership huddle with regional leadership and middle management to inform of daily operations, safety, quality, and service concerns, in order to allow for quicker action and issue resolution.

A micro-analytic approach to understanding electronic health record navigation paths.

Clinician task performance is significantly impacted by the navigational efficiency of the system interface. Here we propose and evaluate a navigational complexity framework useful for examining differences in electronic health record (EHR) interface systems and their impact on task performance. The methodological approach includes 1) expert-based methods-specifically, representational analysis (focused on interface elements), keystroke level modeling (KLM), and cognitive walkthrough; and 2) quantitative analysis of interactive behaviors based on video-captured observations.

Process Mining and Ethnography Study of Medication Reconciliation Tasks.

We studied the medication reconciliation (MedRec) task through analysis of computer logs and ethnographic data. Time spent by healthcare providers performing MedRec was compared between two different EHR systems used at four different regional perioperative settings. Only one of the EHRs used at two settings generated computer logs that supported automatic discovery of the MedRec task.

A Task-Analytic Framework Comparing Preoperative Electronic Health Record-Mediated Nursing Workflow in Different Settings.

Preoperative care is a critical, yet complex, time-sensitive process. Optimization of workflow is challenging for many reasons, including a lack of standard workflow analysis methods. We sought to comprehensively characterize electronic health record-mediated preoperative nursing workflow.

A Time-Driven Activity-Based Costing Analysis of Emergency Department Scribes.

Objective: To apply time-driven activity-based costing (TDABC) methodology to determine emergency medicine physician documentation costs with and without scribes.

Methods: This was a prospective observation cohort study in a large academic emergency department. Two research assistants with experience in physician-scribe interactions and ED workflow shadowed attending physicians for a total of 64 hours in the adult emergency department.

In Search of Vital Signs: A Comparative Study of EHR Documentation.

Vital sign documentation is an essential part of perioperative workflow. Health information technology can introduce complexity into all facets of documentation and burden clinicians with high cognitive load. The Mayo Clinic enterprise is in the process of documenting current EHR-mediated workflow prior to a system-wide EHR conversion.

Multi-Method Study of Electronic Health Records Workflows.

EHRs transform work practices in ways that enhance or impede the quality of care. There is a need for in-depth analysis of EHR workflows, particularly in complex clinical environments. We investigated EHR-basedpre-operative workflows by combining findings from 18 interviews, 7 days of observations, and process mining of EHR interactions from 31 personnel caring for 375 patients at one tertiary referral center.

Time-driven activity-based cost analysis for outpatient anticoagulation therapy: direct costs in a primary care setting with optimal performance.

Objectives: To determine how overall cost of anticoagulation therapy for warfarin compares with that of Novel Oral Anticoagulants (NOACs). Also, to demonstrate a scientific, comprehensive, and an analytical approach to estimate direct costs involved in monitoring and management of anticoagulation therapy for outpatients in an academic primary care clinic setting, post-initiation of therapy.

Methods: A population-based cross-sectional study was conducted in conjunction with observations of patient care processes between August 2014 and January 2015.

Overall Cost Comparison of Gastrointestinal Endoscopic Procedures With Endoscopist- or Anesthesia-Supported Sedation by Activity-Based Costing Techniques.

Objective: Endoscopic/colonoscopic procedures are either done with gastroenterologist-administered conscious sedation or with anesthesia-administered sedation with propofol. There are potential benefits to anesthesia-administered sedation, but the concern has been the associated increased cost.

Methods: To perform this study, we used the time-derived activity-based costing (TDABC) technique to accurately assess the true cost of gastrointestinal procedures done with gastroenterologist-administered conscious sedation vs anesthesia-administered sedation in 2 areas of our practice that use predominantly conscious sedation or anesthesia-administered sedation.

The mayo clinic model of clinical integration.

The multi-campus Academic Health Center (AHC) of the future will need to be system-based and committed to clinical integration to continue to meet institutional goals and serve the needs of its patients. The key tactics we describe to accomplish this are.

Using Process Mining Techniques to Study Workflows in a Pre-operative Setting.

Information technologies have transformed healthcare delivery and promise to improve efficiency and quality of care. However, in-depth analysis of EHR-mediated workflows is challenging. Our goal was to apply process mining, in combination with observational techniques, to understand EHR-based workflows.

Intravenous Alteplase for Acute Stroke and Pulmonary Embolism in a Patient With Recent Abdominoplasty.

Introduction: Major surgery in the past 14 days is a relative contraindication to treatment of acute stroke with intravenous (IV) alteplase. The 2016 American Heart Association/American Stroke Association scientific statement discussing inclusion and exclusion criteria for alteplase in acute stroke allows for provider judgment citing a lack of evidence to support surgery as an absolute contraindication.

Case Report: A 59-year-old woman presented with acute left hemiparesis, dysarthria, and acute respiratory failure.

Serious Pulmonary Toxicity Secondary to Novel Hepatitis C Antiviral Therapy in a Liver Transplant Recipient.

Historically, the treatment of hepatitis C virus infection has been difficult, but therapeutic options have improved markedly recently because of the development of novel antiviral therapies. These therapies have been well tolerated. We describe a patient who was receiving such therapy and had development of temporally related and histologically confirmed severe pulmonary toxicity.

Nitric oxide therapy for post-laparoscopic surgery associated patent foramen ovale: incidence, mechanisms, diagnosis and therapy.

Objective: Postoperative hypoxemia is a common clinical challenge. The diagnosis of an underlying cause of hypoxemia may not immediately be apparent. Clinically silent and non-functional intracardiac shunt may become apparent and pose significant management problems in the postoperative period.

Nitrofurantoin-Induced Granulomatous Interstitial Pneumonia.

Nitrofurantoin-induced lung toxicity is relatively common, but rare histologic patterns sometimes occur that may make diagnosis difficult. We present the case of a 69-year-old woman taking prophylactic nitrofurantoin for urinary tract infections, who developed granulomatous interstitial pneumonia. She improved with cessation of nitrofurantoin, without other therapy.

The expanding role(s) of eosinophils in health and disease.

Surprisingly, the role(s) of eosinophils in health and disease is often summarized by clinicians and basic research scientists as a pervasive consensus opinion first learned in medical/graduate school. Eosinophils are rare white blood cells whose activities are primarily destructive and are only relevant in parasitic infections and asthma. However, is this consensus correct? This review argues that the wealth of available studies investigating the role(s) of eosinophils in both health and disease demonstrates that the activities of these granulocytes are far more expansive and complex than previously appreciated.