Patricia Flatley Brennan, RN, PhD - US grants

DESCRIPTION (Taken from the application abstract): With the current trend toward discharge of cardiac artery bypass graft (CABG) patients from the hospital after five days, nurses must make effective use of existing computer technology to provide more efficiently the services once available during the patient's lengthier hospital stay. The purpose of this project is to develop and test HeartCare, a computerized cardiac recovery program designed to assist nurses with the in-hospital discharge planning and teaching and post-hospital support for self-monitoring, motivation, and home management support that will assist patients to recover from cardiac bypass surgery. Capitalizing on the expansion in health resources on the Internet, this project will employ the World Wide Web platform in the generation of personalized in-home computerized access to recovery resources for use by post-surgical cardiac patients. The revised proposal for a 3-year project clarifies management and better specifies research procedures. One hundred and forty women and men who have undergone cardiac bypass graft surgery will receive standard post-operative care and then be randomized to receive HeartCare, a personalized access to the Internet information and communication resources, a comparison intervention (CHIP, which is an audiotape coaching program), or usual care (a control group). During an experimental patient's index hospitalization, a research nurse will conduct an information needs assessment and use it to tailor access to Internet-based cardiac recovery resources for the individual patient; the patient will take the HeartCare computer home and use it to access locally resident as well as Internet-based resources. Comparison group patients will receive a nursing visit and audio tape; control group patients will receive a data-collection only visit from the research nurse. Patients in the two intervention groups will be encouraged to use their respective services as often as desired in the post-hospital period. Patient outcomes to be measured include physical function, symptom distress, psychological distress, perceived family function, and adherence to cardiac risk behavior modification at four points in time: one week, one month, three months and six months post-discharge. Nurse outcomes of interest include a benchmark of the resources necessary to use HeartCare in practice and a forecast of practice effects of HeartCare obtained through interviews and group assessment techniques. Properly utilized, computer tools that personalize access to Internet resources can help extend key nursing services to patients and ensure that patients achieve their cardiac recovery goals.

The health sciences schools at the University of Wisconsin-Madison are joining together in an Integrated Advanced Management Information Systems (IAIMS) planning initiative. The participants include the Health Sciences Library, the Schools of Medicine, Nursing, Pharmacy and Veterinary Medicine, as well as the University of Wisconsin Hospital and Clinics, the Medical Foundation, the Biological Medical Center and the Wisconsin Network for Health Policy. This initiative is stimulated by two campus initiatives: expansion of the statewide network for health sciences education; and the HealthStar project, a University commitment to dramatically expand the existing health sciences complex facilities clustered at the edge of campus. This expansion involves a new School of Pharmacy building, a large interdisciplinary health sciences research facility, and a Health Sciences Learning Center. New initiatives in public health sciences will occupy a nearby 12-story building. The second focus is to integrate this Madison-based health science complex with education, research, and patient care sites in communities scattered across the state of Wisconsin. All the schools and centers depend heavily on these sites to meet their multiple missions, so increased access and communication are a high priority. Based on these two campus initiatives, this is the right time and opportunity for an IAIMS planning grant at the University.

This training program will prepare nurse scholars to devise, implement and evaluate informational interventions that our patient-centered and responsive to a complex health care system context to generate new knowledge for nursing. Informational interventions include interactions with care recipients in which context is transferred, meanings are shared, and support is given. Patient-centeredness describes the extent to which nurses tailor interventions mindful of, and responsive to, characteristics such as affective states, perceptions, preferences, and resources. The interpersonal context, that is, the situations in which nurses and care recipients encounter each other, vary greatly. Furthermore, contemporary nurse-patient interactions are influenced by multiple and complex external factors, such as social, political, and organizational forces. Nursing research on the content, process, and mode of delivery, of patient-centered, informational interventions are most likely to yield effective results when more attention is given to individual characteristics and to the external factors that impact that interpersonal context. This training program capitalizes on the research strengths of the University of Wisconsin. Investigator-initiated nursing research includes tests of theory-based informational interventions delivered by nurses on a variety of patient behaviors, including breast cancer control, pain control, and regimens to control incontinence. Other researchers in the School are examining contextual factors, which influence patient-centered interventions, including patient preferences and the mode of informational delivery. Campus-wide initiatives supportive of the training effort includes a focus on consumer health, computer technology in health promotion and disease prevention, and illness. The training program will be led by School of Nursing faculty, and supported by Medical, Engineering and Educational Schools' faculty. Support is requested for 10 pre- and 4 post-doctoral candidates. Pre- doctoral candidates will have at least two years of course work in nursing science, inquiry and methods, philosophy of science, and a trainee-directed secondary concentration. Additional research training activities include a training forum, guided research experiences, and an independent research project. Post-doctoral training will be tailored to the trainee's needs, but will include formal courses, participation in seminars and directed research, and conduct of an independent investigation. Trainees will be expected to disseminated their work in writing and at research conferences at least once during the training period.

DESCRIPTION (provided by applicant): Consumer health information producers are generally universities, commercial information producers, and health institutions. Some of the information these entities provide is research oriented while other information is marketing and/or business related. The role of medical libraries is to act as broker of the health information--traditionally to meet the information needs of health professionals. However medical libraries and university health libraries continually expand their patronage to consumers seeking health information effectively changing their role to accommodate the health information needs of consumers. While attempting to meet the health information needs of the public, medical libraries and university health libraries are doing so in an ad hoc fashion. We would like to begin building the foundations of a different model of health information brokering--a community-centered, community-controlled service. This service would be provided by an established community organization, staffed by a professional health librarian or health information professional, and supervised by a board of community health professionals and citizens. The service will not only provide federal, statewide, and local health information to community citizens directly, it will also provide health information evaluation services to health institutions in the community. To demonstrate this, we will design, build, test, and evaluate a prototype service that will lay the foundation for a Community-based Consumer Health Digital Library.

[unreadable] DESCRIPTION (provided by applicant): [unreadable] [unreadable] Patients benefit from access to Internet-based health information and communication resources, but the maximum clinical benefit of consumer health informatics applications awaits integration of these tools with formal clinical services. Therefore, the purpose of this competing continuation is to expand our successful WWW-based information and communication network, HeartCare, from a patient-targeted home-care service to a technology enhanced- practice (TEP) that augments the clinical care provided by home care nurses with electronic information and communication resources. We will work with Aurora Health Care Systems, Milwaukee, WI to conduct a randomized field experiment. This extension of HeartCare will use human factors engineering design strategies to alter the original service with those deemed necessary to support the home care of patients with heart failure. This approach offers significant advantages over the emerging computerized passive home monitoring strategies by providing patients and nurses with relevant information and engaging patients in active self-monitoring and self-management. This study provides an opportunity to understand the context in which consumer health tools can be employed and the extent to which contextual factors affect the design of these tools. This revised proposal retains the original aims and scope of work and addresses three concerns raised by the BLRC: characterization of the intervention, explication of the design process, and clarification of the study period. In addition the revised budget request is 20% lower, reflecting the costs for a full 42-month project. We will undertake a design strategy consistent with sociotechnical systems theory and current approaches to implementation of information systems. We will first use techniques of industrial engineering to conduct a Work Analysis of the home care nurses' practice to (1) identify aspects of practice that could be enhanced by technology (2) better characterize the aspects of the clinical situation likely to be altered by the introduction of consumer health informatics tools. The industrial engineers, Aurora's expert cardiac nurses, and consumers will use the results of the work analysis to design a suite of electronic services including communication, personal health records, and educational materials. These services will integrate Aurora's evidence based heart failure care protocols. Next the TEP nurses will use local "practical" knowledge to plan how they will implement the TEP intervention into their practice. To equalize attention for the control group, electronic copies of nursing references and bulletin board services will be installed on their laptops. We will engage 600 nurse-patient dyads (60 nurses, 10 patients each) in a randomized field experiment. Key outcome variables include patient and nurse satisfaction with care, patient self-management, 30-day readmission rate and nurse workload. [unreadable] [unreadable]

[unreadable] DESCRIPTION (provided by applicant): [unreadable] In this resubmission of an exploratory project applying operations research methods to pricing health information exchange alliances we provide greater detail about the research plan, explicate the ways in which these models can inform business strategy decisions, and report in detail on our preliminary work. Regional health information organizations (RHIOs) form the core building blocks of any approach to creating the National Health Information Network. RHIOs are computer-supported information sharing alliances composed of health care institutions that need to share clinical, financial or administrative data. Institutions considering joining RHIOs require trustable financial projections. Current approaches to health information technology investment rely on a net-present value analysis, which is inadequate to capture the dynamic, uncertain course likely to occur in the RHIO environment. Thus, our team of medical informaticists, operations researchers and computer scientists proposes to apply methods from operations research (real options models and stochastic programming) to aid decision makers in exploring the cost and consequences of various RHIO structures. To insure that the models provide valuable and useful advice to their intended audiences, we will partner with the Indiana Health Information Exchange (IHIE) to characterize the essential business processes, gain real-world data, and solicit concurrent reactions to the models and their output. [unreadable] [unreadable] The long-range goal of this research is to create a suite of decision support tools that can guide RHIO pricing options, discount rates, and optimal configuration choices. However, we must first develop the modeling core of the decision support system. Our approach in this feasibility study will consist of four stages. First, we will obtain preliminary data from our primary industry partner, IHIE, in order to understand the business processes, operational concerns, and strategic priorities of this regional health information exchange. Second, we will use these data to develop preliminary operations research models that capture key aspects of the process under study, namely, formation of information-sharing alliances. Third, we will consult with IHIE and a second partner, the Wisconsin Health Information Exchange, to refine these models, adding to their scope and introducing additional detail and complexity as warranted. Fourth, we will validate our models by examining the decisions they propose through scenario evaluation and simulation studies. Validation will occur at intermediate stages of the process, involving consultation with our partners, comparison with published reports, and computer simulations of evolving information-sharing alliances. [unreadable] [unreadable] Although the operations research methods we propose to use are valid and well established, they have not been applied in a health care information technology decision context. They offer substantial advantage over existing deterministic approaches to economic valuation of health information technologies because they employ multi-period, dynamic stochastic models that explicitly address such important aspects as the impact on one institution of the activity by another institution. We will use the results of this feasibility modeling project to create a proposal to conduct a large-scale test of a suite of models involving awardees of the AHRQ-Connecting Communities for Better Health grants. We will engage additional partners through dissemination and consultation with IHIE and WHIE. [unreadable] [unreadable] [unreadable] [unreadable]

Asthma is a common lung disease with acute and chronic manifestations that impacts more than 22.2 million Americans or 7.9% of the population, including over 6.7 million children younger than 18 years of age. The cost of asthma is significant both for individuals and for the society as a whole. It is highly desirable to establish transformative technologies to improve the patient quality of life and reduce the cost of asthma management. The recent development in sensor and mobile computing technology provide great opportunities to establish Smart Asthma Management (SAM) systems and achieve a quantum leap in asthma management. Leveraging on the fast development of information infrastructure, patients can create a detailed temporal log recording their symptoms, medicine usage, and possibly vital physiological signals through an easy access to a website or their smart phones in SAM systems. This unprecedented continuous stream of patient-generated data in SAM systems provides us significant opportunities to better estimate patient condition and make clinical intervention decisions. However, since the information infrastructure of SAM has not become available until recently, very limited work is available for SAM systems. Against this background, this collaborative project aims to develop a suite of statistical modeling, monitoring, prognosis, and clinical intervention decision making methodologies based on a flexible yet rigorous multistate model to describe the evolving of patient conditions. The true underlying state of the patient is assumed unknown; however, there is reason to expect that it could be inferred from patient generated data such as the frequency of the rescue inhaler usage (the time and frequency of the rescue inhaler use is an important indicator of asthma control).

Some anticipated advances include: (i) Multistate model with event intensity function as observations. The proposed methodology brings the mixed effect model and the multistate model into a unified framework to integrate the population information embedded in the historical records of multiple patients and the individual information collected in real-time in a quantitative way. (ii) Stochastic filtering approach for individual patient condition modeling and updating. The novel state space formulation enables efficient stochastic filtering algorithms to estimate and update the states and parameters in the multistate model. (iii) Clinical intervention decision support for patients and clinicians. The salient features of the proposed policy are that it is based on a condition-based policy and incorporates uncertainties in the patient condition model through a Partially Observable Markov Decision Process (POMDP) framework which has been widely used and proven to be very effective in the management of industrial systems. Plans are in place to evaluate the effectiveness of the resulting technologies in collaboration with clinical experts.


The project is likely to contribute predictive technologies that could help reduce the cost and improve the quality of healthcare in the US, especially as it relates to effective management of chronic illnessess. Additional broader impacts of the project include enhanced research-based training opportunities for graduate and undergraduate students (including members of under-represented minorities) in healthcare engineering, statistics, and operation research; enrichment of the curricula in health systems in industrial engineering and operations research at the University of Wisconsin-Madison and the University of Iowa.