The Electronic Health Record Scorecard: A Measure of Utilization and Communication Skills

As the adoption rate of electronic health records (EHRs) in the United States continues to grow, both providers and patients will need to adapt to the reality of a third actor being present during the visit encounter. The purpose of this project is to provide insight on “best” practice patterns for effective communication and efficient use of the EHR in the clinical practice setting. Through the development of a comprehensive scorecard, this project assessed current status of EHR use and communication skills among health care providers in various clinical practice settings. Anticipated benefits of this project are increased comfortability in interfacing with the EHR and increased satisfaction on the part of the provider as well as the patient. Serving as a benchmark, this assessment has the potential to help guide future health information technology development, training, and education for both students and health care providers

Provider Use of a Novel EHR display in the Pediatric Intensive Care Unit. Large Customizable Interactive Monitor (LCIM)

OBJECTIVES: The purpose of this study was to explore providers' perspectives on the use of a novel technology, "Large Customizable Interactive Monitor" (LCIM), a novel application of the electronic health record system implemented in a Pediatric Intensive Care Unit. METHODS: We employed a qualitative approach to collect and analyze data from pediatric intensive care physicians, pediatric nurse practitioners, and acute care specialists. Using semi-structured interviews, we collected data from January to April, 2015. The research team analyzed the transcripts using an iterative coding method to identify common themes. RESULTS: Study results highlight contextual data on providers' use routines of the LCIM. Findings from thirty six interviews were classified into three groups: 1) providers' familiarity with the LCIM; 2) providers' use routines (i.e. when and how they use it); and 3) reasons why they use or do not use it. CONCLUSION: It is important to conduct baseline studies of the use of novel technologies. The importance of training and orientation affects the adoption and use patterns of this new technology. This study is notable for being the first to investigate a LCIM system, a next generation system implemented in the pediatric critical care setting. Our study revealed this next generation HIT might have great potential for family-centered rounds, team education during rounds, and family education/engagement in their child's health in the patient room. This study also highlights the effect of training and orientation on the adoption patterns of new technology

Differences in Physician Use of Electronic Health Records: Development of a Scale Assessing Individual Factors Influencing Physician Actualization

Electronic health records (EHRs) are one of the most talked about topics within and surrounding health care organizations and the health care system in the United States; however, the U.S. has been slow to implement these computerized medical record systems into their organizations. One of the factors often overlooked regarding the implementation of EHRs, is the role of individual health care professionals and the effects produced by their interactions with the EHR as they perform their job duties throughout the day. Using a Theory of Organization-EHR Affordance Actualization as a guiding framework, the focus of this dissertation is to examine the factors that influence how physicians use the EHR at the individual-level during clinical interactions by analyzing physician perceptions of their interaction with the EHR while providing patient care in the exam room and how it influences their work process. A mixed methods approach was used to identify the affordances, EHR features, factors that influence EHR use, and individual physician characteristics that produce the visible effects of EHR use during the clinical encounter when individual physicians interact with the EHR. The findings of this study confirm the identification of individual level affordances proposed by Strong and colleagues and propose three additional affordances. This study also identified additional features that should be taken into consideration when investigating individual level affordance actualization. Finally, this study provides a survey tool for practice managers, health care executives, trainers, and vendors to use in order to better understand the individual user characteristics of their physicians, predict their patterns of use based on these user characteristics, and thus tailor their training to enhance affordance actualization and organizational goal attainment

Electronic Health Record Implementation Strategies for Decreasing Healthcare Costs

Some managers of primary care provider (PCP) facilities lack the strategies to implement electronic health records (EHRs), which could decrease healthcare costs and enhance the efficiency and quality of healthcare that patients receive. The purpose of this single-case study was to explore the strategies PCP managers used to implement EHRs to decrease healthcare costs. The population consisted of 5 primary care managers with responsibility for the administration, oversight, and direct working knowledge of EHRs in Central Florida. The conceptual framework was the technology acceptance model. Data were collected from semistructured face-to-face interviews and the review of company documents, including training logs, activity records, and cost information. Methodological triangulation was used to validate the creditability and interpretation of the data in transcribing themes. Three themes emerged from the analysis of study data: implementation of EHRs, costs of implementing EHRs, and perceived usefulness of EHRs. Participants indicated that the implementation of EHRs depended on motivation, financial cost, and the usefulness of EHRs relating to training that reflected user-friendliness. The implications of this study for social change include the potential to lower the cost and improve the efficiency of healthcare for patients. The use of EHR systems could enhance the quality of care delivered to patients through improved accessibility, elimination of duplicative tests, and retrieval of accurate patient information. The use of EHRs can lead to a comprehensive preventative healthcare system resulting in a healthier environment

Doctor of Philosophy

dissertationClinical decision support systems (CDSS) and electronic health records (EHR) have been widely adopted but do not support a high level of reasoning for the clinician. As a result, workflow incongruity and provider frustrations lead to more errors in reasoning. Other successful fields such as defense, aviation, and the military have used task complexity as a key factor in decision support system development. Task complexity arises during the interaction of the user and the tasks. Therefore, in this dissertation I have utilized different human factor methods to explore task complexity factors to understand their utility in health information technology system design. The first study addresses the question of generalizing complexity through a clinical complexity model. In this study, we integrated and validated a patient and task complexity model into a clinical complexity model tailored towards healthcare to serve as the initial framework for data analysis in our subsequent studies. The second study addresses the question of the coping strategies of infectious disease (ID) clinicians while dealing with complex decision tasks. The study concluded that clinicians use multiple cognitive strategies that help them to switch between automatic cognitive processes and analytical processes. The third study identified the complexity contributing factors from the transcripts of the observations conducted in the ID domain. The clinical complexity model developed in the first study guided the research for identifying the prominent complexity iv factors to recommend innovative healthcare technology system design. The fourth study, a pilot exploratory study, demonstrated the feasibility of developing a population information display from querying real complex patient information from an actual clinical database as well as identifying the ideal features of population information display. In summary, this dissertation adds to the knowledge about how clinicians adapt their information environment to deal with complexity. First, it contributes by developing a clinical complexity model that integrates both patient and task complexity. Second, it provides specific design recommendations for future innovative health information technology systems. Last, this dissertation also suggests that understanding task complexity in the healthcare team domain may help to better design of interface system

User Interfaces for Patient-Centered Communication of Health Status and Care Progress

The recent trend toward patients participating in their own healthcare has opened up numerous opportunities for computing research. This dissertation focuses on how technology can foster this participation, through user interfaces to effectively communicate personal health status and care progress to hospital patients. I first characterize the design space for electronic information communication to patients through field studies conducted in multiple hospital settings. These studies utilize a combination of survey instruments, and low- and high-fidelity prototypes, including a document-editing prototype through which users can view and manage clinical data to automatically associate it with progress notes. The prototype, activeNotes, includes the first known techniques supporting clinical information requests directly within a document editor. A usage study with ICU physicians at New York-Presbyterian Hospital (NYP) substantiated our design and revealed how electronic information related to patient status and care progress is derived from a typical Electronic Health Record system. Insights gained from this study informed following studies to understand how to design abstracted, plain-language views suitable for patients. We gauged both patient and physician responses to information display prototypes deployed in patient rooms for a formative study exploring their design. Following my reports on this study, I discuss the design, development and pilot evaluations of a prototype Personal Health Record application providing live, abstracted clinical information for patients at NYP. The portal, evaluated by cardiothoracic surgery patients, is the first of its kind to allow patients to capture and monitor live data related to their care. Patient use of the portal influenced the subsequent design of tools to support users in making sense of online medication information. These tools, designed with nurses and pharmacists and evaluated by cardiothoracic surgery patients at NYP, were developed using topic modeling approaches and text analysis techniques. Embodied in a prototype called Remedy, they enable rapid filtering and comparison of medication-related search results, based on a number of website features and content topics. I conclude by discussing how findings from this series of studies can help shape the ongoing design and development of patient-centered technology

Electronic Health Record Optimization for Cardiac Care

Electronic health record (EHR) systems have been studied for over 30 years, and despite the benefits of information technology in other knowledge domains, progress has been slow in healthcare. A growing body of evidence suggests that dissatisfaction with EHR systems was not simply due to resistance to adoption of new technology but also due to real concerns about the adverse impact of EHRs on the delivery of patient care. Solutions for EHR improvement require an approach that combines an understanding of technology adoption with the complexity of the social and technical elements of the US healthcare system. Several studies are presented to clarify and propose a new framework to study EHR-provider interaction. Four focus areas were defined - workflow, communication, medical decision-making and patient care. Using Human Computer Interaction best practices, an EHR usability framework was designed to include a realistic clinical scenario, a cognitive walkthrough, a standardized simulated patient actor, and a portable usability lab. Cardiologists, fellows and nurse practitioners were invited to participate in a simulation to use their institution’s EHR system for a routine cardiac visit. Using a mixed methods approach, differences in satisfaction and effectiveness were identified. Cardiologists were dissatisfied with EHR functionality, and were critical of the potential impact of the communication of incorrect information, while displaying the highest level of success in completing the tasks. Fellows were slightly less dissatisfied with their EHR interaction, and demonstrated a preference for tools to improve workflow and support decision-making, and showed less success in completing the tasks in the scenario. Nurse practitioners were also dissatisfied with their EHR interaction, and cited poor organization of data, yet demonstrated more success than fellows in successful completion of tasks. Study results indicate that requirements for EHR functionality differ by type of provider. Cardiologists, cardiology fellows, and nurse practitioners required different levels of granularity of patient data for use in medical decision-making, defined different targets for communication, sought different solutions to workflow which included distribution of data input, and requested technical solutions to ensure valid and relevant patient data. These findings provide a foundation for future work to optimize EHR functionality

Physicians’ Perceptions of Facilitators and Barriers in Electronic Health Record Education

A significant focus in health care is quality documentation to lower patient safety risks. The local problem at a healthcare organization in the northeastern United States is that some physicians are falling short with quality documentation of patient care in athenaNet, a cloud-based electronic health record (EHR). This qualitative case study was conducted to explore physicians\u27 perceptions of the facilitators and barriers that impact the educational process for quality documentation in EHRs. Attention also focused on identifying physicians\u27 recommendations for enhancing the educational process for quality documentation. Knowles’ adult learning theory served as the conceptual framework. Purposeful sampling was used to select participants who had a minimum of 5 years’ experience as a physician and had worked with multiple EHRs in the past. Individual interviews with 11 physicians were supplemented with review of documents in athenaNet on milestones in physician documentation. Data analysis included coding of interview transcripts and information from documents to identify common themes: (a) preparation for implementation, (b) specialty-specific training, (c) hands-on practice, (d) time limitations on completing training, (e) preparedness for EHR go-live, and (f) additional training resources. Findings of the study were used to develop a white paper to increase the quality of the documentation entered into an EHR, and to lower patient safety risks through more effective continuing education. The study contributes to positive social change through modifications to the current training methodology for the EHR as a solution to assisting physicians to complete quality documentation

COMBINING HUMAN FACTORS AND DATA SCIENCE METHODS TO EVALUATE THE USE OF FREE TEXT COMMUNICATION ORDERS IN ELECTRONIC HEALTH RECORDS

Medication errors are a leading cause of death in the United States. Electronic Health Records (EHR) along with Computerized Provider Order Entry (CPOE) are considered promising ways to reduce these errors. However, EHR systems have not eliminated medication errors. Moreover, in some cases they have facilitated errors due to issues such as poor usability and negative effects on clinical workflows. The use of unexpected free text within a CPOE system can serve as a marker that the system does not adequately support clinical workflow. Prior studies have looked at the use of free text within medication orders, but the inclusion of medication related information in communication for non-medication orders (CNMOs), a type of free text order, has not been adequately studied. This mixed-methods study identified the prevalence, nature and reasons for the inclusion of medication related information in CNMOs using a large sample of CNMOs placed at a mid-Atlantic hospital system in 2017, and via interviews with physicians. The study found that more than 42% of CNMOs contain medication related information. Moreover, the use of CNMOs varied significantly across provider types, hospital locations, patient settings and other factors. The study found 10 themes that might cause providers to adopt such workarounds, including missing functionality and poor usability. The viii study also identified several general challenges in communicating medication information in the EHR, and potential solutions to mitigate these challenges. This dissertation also demonstrates how natural language processing could be used to identify medication related CNMOs