Simulation-Based Electronic Health Record Usability Evaluation: A Proof of Concept

Poor usability of Electronic Health Records (EHR) solutions is directly associated with physician burnout. While the survey and observational methods have been utilized widely in the usability evaluation of EHRs, it does not seem to be helping with the continuous improvement of EHR design and user satisfaction. We address this gap by presenting a discrete event simulation-based model that can add objectivity to the extant EHR usability methods. Evaluating EHR usability from the perspective of operations and workflow can help vendors design and develop better systems. This short paper presents a proof-of-concept simulation model with assumed task-time distributions. Our main research question is how we can use simulation techniques to objectively evaluate EHR usability? The simulation model results in terms of resource (clinician) utilization metrics can serve as a proxy to evaluate the efficiency component of the EHR usability at the departmental leve

Integrating historical clinical and financial data for pharmacological research

pre-printBackground: Retrospective research requires longitudinal data, and repositories derived from electronic health records (EHR) can be sources of such data. With Health Information Technology for Economic and Clinical Health (HITECH) Act meaningful use provisions, many institutions are expected to adopt EHRs, but may be left with large amounts of financial and historical clinical data, which can differ significantly from data obtained from newer systems, due to lack or inconsistent use of controlled medical terminologies (CMT) in older systems. We examined different approaches for semantic enrichment of financial data with CMT, and integration of clinical data from disparate historical and current sources for research. Methods: Snapshots of financial data from 1999, 2004 and 2009 were mapped automatically to the current inpatient pharmacy catalog, and enriched with RxNorm. Administrative metadata from financial and dispensing systems, RxNorm and two commercial pharmacy vocabularies were used to integrate data from current and historical inpatient pharmacy modules, and the outpatient EHR. Data integration approaches were compared using percentages of automated matches, and effects on cohort size of a retrospective study. Results: During 1999-2009, 71.52%-90.08% of items in use from the financial catalog were enriched using RxNorm; 64.95%-70.37% of items in use from the historical inpatient system were integrated using RxNorm, 85.96%-91.67% using a commercial vocabulary, 87.19%-94.23% using financial metadata, and 77.20%-94.68% using dispensing metadata. During 1999-2009, 48.01%-30.72% of items in use from the outpatient catalog were integrated using RxNorm, and 79.27%-48.60% using a commercial vocabulary. In a cohort of 16304 inpatients obtained from clinical systems, 4172 (25.58%) were found exclusively through integration of historical clinical data, while 15978 (98%) could be identified using semantically enriched financial data. Conclusions: Data integration using metadata from financial/dispensing systems and pharmacy vocabularies were comparable. Given the current state of EHR adoption, semantic enrichment of financial data and integration of historical clinical data would allow the repurposing of these data for research. With the push for HITECH meaningful use, institutions that are transitioning to newer EHRs will be able to use their older financial and clinical data for research using these methods

The role of electronic records in the integration of oral health and primary care services in community health centers

BACKGROUND: Medical-Dental integration involves the provision of fluoride varnish application, caries risk assessment, anticipatory guidance, and provision of dental referrals by pediatricians during well-child visits. Integration has been recommended as a means to increase access to quality dental care for patients from racial and ethnic minority groups who are at an increased risk of developing oral health problems. METHODS: Guided by the RE-AIM framework (Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance), this case study explored the barriers and facilitators for the incorporation of a medical-dental integration program at two community health centers in Massachusetts. Specifically, this study explored the degree to which electronic records were instrumental in the provision and documentation of oral health preventive services during pediatric primary care at the study sites. Data sources included analysis of records from 2014–2015 (before integration) to those from 2016-2018 (post integration), interviews with staff, clinicians, and administrators and direct observations of the workflow at dental and pediatric medicine departments in the study sites. A General Estimating Equation Analysis was conducted to estimate the odds of application of oral health preventive measures before and after electronic dental and medical electronic records were integrated at one of the sites. FINDINGS: During the years post-record integration, children were 40.3 times more likely to receive dental screenings, 2.7 times more likely to receive fluoride varnish during well child visits and 1.6 times more likely to receive fluoride in the dental department within six months of their well child visits compared to the period prior to integration. Respondents identified the complexity, ease of use and accessibility of tools within the electronic medical records as significant factors in success of integration efforts. CONCLUSIONS: Community health centers interested in successfully implementing a medical-dental integration model should invest in sufficient workflow and training resources for the transition to the new records system, develop a simplified protocol for the application of dental preventive services, design accessible electronic tools for documentation of services, and establish accurate reporting systems for both internal program monitoring and external surveillance purposes

A standards-based ICT framework to enable a service-oriented approach to clinical decision support

This research provides evidence that standards based Clinical Decision Support (CDS) at the point of care is an essential ingredient of electronic healthcare service delivery. A Service Oriented Architecture (SOA) based solution is explored, that serves as a task management system to coordinate complex distributed and disparate IT systems, processes and resources (human and computer) to provide standards based CDS. This research offers a solution to the challenges in implementing computerised CDS such as integration with heterogeneous legacy systems. Reuse of components and services to reduce costs and save time. The benefits of a sharable CDS service that can be reused by different healthcare practitioners to provide collaborative patient care is demonstrated. This solution provides orchestration among different services by extracting data from sources like patient databases, clinical knowledge bases and evidence-based clinical guidelines (CGs) in order to facilitate multiple CDS requests coming from different healthcare settings. This architecture aims to aid users at different levels of Healthcare Delivery Organizations (HCOs) to maintain a CDS repository, along with monitoring and managing services, thus enabling transparency. The research employs the Design Science research methodology (DSRM) combined with The Open Group Architecture Framework (TOGAF), an open source group initiative for Enterprise Architecture Framework (EAF). DSRM’s iterative capability addresses the rapidly evolving nature of workflows in healthcare. This SOA based solution uses standards-based open source technologies and platforms, the latest healthcare standards by HL7 and OMG, Decision Support Service (DSS) and Retrieve, Update Locate Service (RLUS) standard. Combining business process management (BPM) technologies, business rules with SOA ensures the HCO’s capability to manage its processes. This architectural solution is evaluated by successfully implementing evidence based CGs at the point of care in areas such as; a) Diagnostics (Chronic Obstructive Disease), b) Urgent Referral (Lung Cancer), c) Genome testing and integration with CDS in screening (Lynch’s syndrome). In addition to medical care, the CDS solution can benefit organizational processes for collaborative care delivery by connecting patients, physicians and other associated members. This framework facilitates integration of different types of CDS ideal for the different healthcare processes, enabling sharable CDS capabilities within and across organizations

Methods to Facilitate the Capture, Use, and Reuse of Structured and Unstructured Clinical Data.

Electronic health records (EHRs) have great potential to improve quality of care and to support clinical and translational research. While EHRs are being increasingly implemented in U.S. hospitals and clinics, their anticipated benefits have been largely unachieved or underachieved. Among many factors, tedious documentation requirements and the lack of effective information retrieval tools to access and reuse data are two key reasons accounting for this deficiency. In this dissertation, I describe my research on developing novel methods to facilitate the capture, use, and reuse of both structured and unstructured clinical data. Specifically, I develop a framework to investigate potential issues in this research topic, with a focus on three significant challenges. The first challenge is structured data entry (SDE), which can be facilitated by four effective strategies based on my systematic review. I further propose a multi-strategy model to guide the development of future SDE applications. In the follow-up study, I focus on workflow integration and evaluate the feasibility of using EHR audit trail logs for clinical workflow analysis. The second challenge is the use of clinical narratives, which can be supported by my innovative information retrieval (IR) technique called “semantically-based query recommendation (SBQR)”. My user experiment shows that SBQR can help improve the perceived performance of a medical IR system, and may work better on search tasks with average difficulty. The third challenge involves reusing EHR data as a reference standard to benchmark the quality of other health-related information. My study assesses the readability of trial descriptions on ClinicalTrials.gov and found that trial descriptions are very hard to read, even harder than clinical notes. My dissertation has several contributions. First, it conducts pioneer studies with innovative methods to improve the capture, use, and reuse of clinical data. Second, my dissertation provides successful examples for investigators who would like to conduct interdisciplinary research in the field of health informatics. Third, the framework of my research can be a great tool to generate future research agenda in clinical documentation and EHRs. I will continue exploring innovative and effective methods to maximize the value of EHRs.PHDInformationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/135845/1/tzuyu_1.pd