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  • Author
    Sarah Park
  • PI

    Dr. Maryam Liaqat

  • Co-Author

  • Title

    Clinical Ethnographic Research in Dermatology

  • Program

    STTP

  • Other Program (if not listed above)

  • Abstract

    Title: Clinical Ethnographic Research in Dermatology

    Background: The Biodesign process provides a framework to observe and address the shortcomings of health care encountered in daily clinical practice. This approach is rooted in bedside-to-bench-to-bedside innovation rather than bench-to-bedside innovation. In order to engage in the Biodesign process and train as a clinical ethnographer, I looked to identify the most pressing unmet clinical needs within UCLA Division of Dermatology. I conducted an ethnographic research study within Dermatology at the Santa Monica Clinic. Opportunities to improve clinic workflow were identified through weekly clinical immersion that consisted of ethnography and interviews of health care staff. This study serves as an example of how the Biodesign framework may be useful for identifying needs that impact patient care in an ambulatory clinic like dermatology.

    Methods: An ethnographic study was conducted for 7 weeks from June 1, 2021 to July 13, 2021 and comprised of a hybrid of observation and interview-based insight extraction. Clinical practice was observed in multiple specialty clinics of dermatology, including the pigmented lesions clinic, skin of color clinic, medical dermatology continuity clinic and cosmetic dermatology clinic. Common dermatologic cosmetic procedures including lasers and Mohs micrographic surgery were also observed. Clinical practice was first observed and was followed by interviews with different stakeholders in the healthcare team.

    Skills learned during the Sling Health didactic sessions were used to validate needs and create solution concepts. Mind mapping, root cause analyses, iterations of clinical immersion and interviews were used to extract and validate needs. Genealogy mapping was used to generate solution concepts.

    Results:

    A total of 56 hours of clinical immersion and ethnography were conducted. During this time, 23 needs were identified, and 16 stakeholders were interviewed. Of those 23 needs, two were prioritized and solution concepts were generated.

    An initial observation of a high-risk skin cancer patient who presented to the clinic months after the physician-advised interval, prompted the question of whether there were difficulties in making appointments. Multiple iterations of observations and interviews revealed that existing scheduling protocols can result in barriers to essential follow-up. Three root problems were identified. First, scheduling currently exists only for appointments occurring within the next 6 months. Patients who come in for annual skin checks need to make the appointment 6 months later. Second, patients who do not schedule physician-recommended interval appointments (i.e., 1 month follow-up) at the time of checkout are not automatically contacted to facilitate the next visit appointment. Lastly, dermatologists are on average fully booked for 1-2 months and patients have difficulty finding earlier appointments. From these root causes, the need was extracted and then validated through interviews with multiple stakeholders including physicians, front desk staff, and administrative personnel. UCLA Dermatology needs an autogenerated method to contact patients before the physician-recommended interval to schedule their appointments in order to improve patient care. Addressing this need is essential to patient care because ensuring continuity of care can lead to earlier diagnosis, earlier intervention, and better prognosis of any new development of skin cancers.

    The second need was extracted through an interview with the UCLA Dermatology medication prior authorization coordinator and then validated through physicians and administrative staff. Avoidable delays occur when physicians do not document the percent body surface area (BSA) when prescribing high-risk medications such as biologics. The average time for approval when BSA is documented is 3-5 days, but inadequate documentation could cause delay this process by days or even weeks. These delays come at a high cost and morbidity to patients and can lead to exacerbations of severe, acute, or chronic illnesses. UCLA Dermatology needs a means to ensure that specific information is documented before a high-risk medication is prescribed in order to reduce automatic rejections of prior authorizations.

    Finally, solution concepts for both needs were generated. The proposed solution is to send autogenerated reminders to patients to schedule their appointments at least 1 month before the physician-recommended follow-up interval via MyChart UCLA health portal, text messaging, or phone calls. The second proposed solution was to create hard stops in the system to ensure BSA is included.

    Conclusion: In the Dermatology clinic at Santa Monica, patients may have challenges navigating the scheduling protocol and receiving medications in a timely manner. Efforts should be focused on identifying unmet clinical needs and optimizing clinic workflow. Opportunities for improvement of patient care include sending autogenerated reminders to schedule patient appointments and separately, creating quality control measures on the physician’s end to ensure necessary documentation. Future directions include quantifying the number of patients who are currently affected by existing protocols, implementing solutions, and quantifying subsequent improvements in care and patient outcomes.

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    https://uclahs.zoom.us/j/98323050055?pwd=UG5Nc3pIK2JKUm1XbFBobk8wcjl4UT09