Integrating Clinical Decision Support into Workflow

Purpose: The aims were to (1) identify barriers and facilitators related to integration of clinical decision support (CDS) into workflow and (2) develop and test CDS design alternatives. Scope: To better understand CDS integration, we studied its use in practice, focusing on CDS for colorectal cancer (CRC) screening and followup. Phase 1 involved outpatient clinics of four different systems—120 clinic staff and providers and 118 patients were observed. In Phase 2, prototyped design enhancements to the Veterans Administration’s CRC screening reminder were compared against its current reminder in a simulation experiment. Twelve providers participated. Methods: Phase 1 was a qualitative project, using key informant interviews, direct observation, opportunistic interviews, and focus groups. All data were analyzed using a coding template, based on the sociotechnical systems theory, which was modified as coding proceeded and themes emerged. Phase 2 consisted of rapid prototyping of CDS design alternatives based on Phase 1 findings and a simulation experiment to test these design changes in a within-subject comparison. Results: Very different CDS types existed across sites, yet there are common barriers: (1) lack of coordination of “outside” results and between primary and specialty care; (2) suboptimal data organization and presentation; (3) needed provider and patient education; (4) needed interface flexibility; (5) needed technological enhancements; (6) unclear role assignments; (7) organizational issues; and (8) disconnect with quality reporting. Design enhancements positively impacted usability and workflow integration but not workload. Conclusions: Effective CDS design and integration requires: (1) organizational and workflow integration; (2) integrating outside results; (3) improving data organization and presentation in a flexible interface; and (4) providing just-in time education, cognitive support, and quality reporting

Linking Research and Policy: Assessing a Framework for Organic Agricultural Support in Ireland

This paper links social science research and agricultural policy through an analysis of support for organic agriculture and food. Globally, sales of organic food have experienced 20% annual increases for the past two decades, and represent the fastest growing segment of the grocery market. Although consumer interest has increased, farmers are not keeping up with demand. This is partly due to a lack of political support provided to farmers in their transition from conventional to organic production. Support policies vary by country and in some nations, such as the US, vary by state/province. There have been few attempts to document the types of support currently in place. This research draws on an existing Framework tool to investigate regionally specific and relevant policy support available to organic farmers in Ireland. This exploratory study develops a case study of Ireland within the framework of ten key categories of organic agricultural support: leadership, policy, research, technical support, financial support, marketing and promotion, education and information, consumer issues, inter-agency activities, and future developments. Data from the Irish Department of Agriculture, Fisheries and Food, the Irish Agriculture and Food Development Authority (Teagasc), and other governmental and semi-governmental agencies provide the basis for an assessment of support in each category. Assessments are based on the number of activities, availability of information to farmers, and attention from governmental personnel for each of the ten categories. This policy framework is a valuable tool for farmers, researchers, state agencies, and citizen groups seeking to document existing types of organic agricultural support and discover policy areas which deserve more attention

Modeling Clinicians’ Cognitive and Collaborative Work in Post-Operative Hospital Care

abstract: Clinicians confront formidable challenges with information management and coordination activities. When not properly integrated into clinical workflow, technologies can further burden clinicians’ cognitive resources, which is associated with medical errors and risks to patient safety. An understanding of workflow is necessary to redesign information technologies (IT) that better support clinical processes. This is particularly important in surgical care, which is among the most clinical and resource intensive settings in healthcare, and is associated with a high rate of adverse events. There are a growing number of tools to study workflow; however, few produce the kinds of in-depth analyses needed to understand health IT-mediated workflow. The goals of this research are to: (1) investigate and model workflow and communication processes across technologies and care team members in post-operative hospital care; (2) introduce a mixed-method framework, and (3) demonstrate the framework by examining two health IT-mediated tasks. This research draws on distributed cognition and cognitive engineering theories to develop a micro-analytic strategy in which workflow is broken down into constituent people, artifacts, information, and the interactions between them. It models the interactions that enable information flow across people and artifacts, and identifies dependencies between them. This research found that clinicians manage information in particular ways to facilitate planned and emergent decision-making and coordination processes. Barriers to information flow include frequent information transfers, clinical reasoning absent in documents, conflicting and redundant data across documents and applications, and that clinicians are burdened as information managers. This research also shows there is enormous variation in how clinicians interact with electronic health records (EHRs) to complete routine tasks. Variation is best evidenced by patterns that occur for only one patient case and patterns that contain repeated events. Variation is associated with the users’ experience (EHR and clinical), patient case complexity, and a lack of cognitive support provided by the system to help the user find and synthesize information. The methodology is used to assess how health IT can be improved to better support clinicians’ information management and coordination processes (e.g., context-sensitive design), and to inform how resources can best be allocated for clinician observation and training.Dissertation/ThesisDoctoral Dissertation Biomedical Informatics 201

Electronic Falls Reporting System Implementation: Evaluating Data Collection Methods and Studying User Acceptance

In this research, we detail the development of a novel, easy-to-use system to facilitate electronic patient falls reporting within a long-term residential care facility (LTRCF) using off-the-shelf technology that can be inexpensively implemented in a wide variety of settings. We report the results of four complimentary system evaluation measures that take into consideration varied organizational stakeholders’ perspectives: 1) System-level benefits and costs, 2) System usability, via scenario-based use cases, 3) A holistic assessment of users’ physical, cognitive, and marcoergonomic (work system) challenges in using the system, and 4) User technology acceptance. We report the viability of collecting and analyzing data specific to each evaluation measure and detail the relative merits of each measure in judging whether the system is acceptable to each stakeholder. The electronic falls reporting system was successfully implemented, with 100% electronic submission rate at 3-months post-implementation period. The system-level benefits and costs approach showed that the electronic system required no initial investment costs aside from personnel costs and significant benefits accrued from user time savings. The usability analysis revealed several fixable design flaws and demonstrated the importance of scenario-based user training. The technology acceptance model showed that users perceived the reporting system to be useful and easy to use, even more so after implementation. Finally, the holistic human factors evaluation identified challenges encountered when nurses used the system as a part of their daily work, guiding further system redesign. The four-pronged evaluation framework accounted for varied stakeholder perspectives and goals and is a highly scalable framework that can be easily applied to Health IT (Information Technology) implementations in other LTRCFs

Transactions of the First International Conference on Health Information Technology Advancement vol. 1, no. 1

Full proceedings of The First International Conference on Health Information Technology Advancement held at Western Michigan University in Kalamazoo, Michigan on October 28, 2011. Conference Co-Chairs: Dr. Bernard Han, Director of the Center for HIT Advancement (CHITA) at Western Michigan University Dr. Sharie Falan, Associate Director of the Center for HIT Advancement (CHITA) at Western Michigan University Transactions Editor: Dr. Huei Lee, Professor in the Department of Computer Information Systems at Eastern Michigan Universit

Master of Science

thesisThough medical advances in the last century now allow us to forestall death, many patients suffer from significant symptoms as they battle severe disease. Opioid medications are particularly effective when treating pain in these patients and infusion by the patient controlled analgesia (PCA) paradigm is commonly used in patients with severe disease. While PCA allows rapid titration yet individualized adjustment of opioid dose, it involves complex, high-stakes decisions. Unfortunately, clinicians complain that it is often difficult or impossible to find the data needed to make these decisions. A relevant data display could support clinical decisions by providing real-time up-to-date clinical data at the point of care. Literature synthesis and multiple modeling techniques were used to quantify the domain. An inductive, qualitative approach, including graphical mapping techniques, was used to build a foundational domain information model which was subsequently validated using a survey of domain experts. A gap analysis was performed, mapping concepts from the information model to the emerging HL7 FHIR standard. Modeling revealed a complex workflow, highlighted the bottleneck in information flow to providers at the point of care, and supported the premise that a relevant data display would be beneficial. The gap analysis showed that currently existing FHIR resources are capable of representing all relevant concepts from the domain information model needed for decision making in this complex use-case. Potential problems with FHIR implementation were identified and recommendations to address these are presented

Transactions of 2015 International Conference on Health Information Technology Advancement Vol.3, No. 1

The Third International Conference on Health Information Technology Advancement Kalamazoo, Michigan, October 30-31, 2015 Conference Chair Bernard Han, Ph.D., HIT Pro Department of Business Information Systems Haworth College of Business Western Michigan University Kalamazoo, MI 49008 Transactions Editor Dr. Huei Lee, Professor Department of Computer Information Systems Eastern Michigan University Ypsilanti, MI 48197 Volume 3, No. 1 Hosted by The Center for Health Information Technology Advancement, WM

Usability analysis of contending electronic health record systems

In this paper, we report measured usability of two leading EHR systems during procurement. A total of 18 users participated in paired-usability testing of three scenarios: ordering and managing medications by an outpatient physician, medicine administration by an inpatient nurse and scheduling of appointments by nursing staff. Data for audio, screen capture, satisfaction rating, task success and errors made was collected during testing. We found a clear difference between the systems for percentage of successfully completed tasks, two different satisfaction measures and perceived learnability when looking at the results over all scenarios. We conclude that usability should be evaluated during procurement and the difference in usability between systems could be revealed even with fewer measures than were used in our study. © 2019 American Psychological Association Inc. All rights reserved.Peer reviewe

The Impact of Individual Learning on Electronic Health Record Routinization: An Empirical Study

Since the passage of the HITECH Act, adoption of electronic health records (EHR) has increased significantly EHR refers to an electronic version of a patient’s medical history. The adoption of EHR has potential to reduce medical errors, duplication of testing, and delays in treatment. However, current literature indicates that implementation of EHR is not resulting in the automatic routinization of EHR. Routinization refers to the notion that truly successful technological innovations are no longer perceived as being new or out-of-the-ordinary. The complexity of EHRs allow individual users to use these systems at different levels of sophistication. Research shows that healthcare professionals are using non-standard ways to use or circumvent the EHR to complete their work and are limited in EHR systems use. Further, although workarounds may seem necessary to physicians and are not perceived to be problematic, they can pose a threat to patient safety and hinder the potential benefits. Hence, we argue the EHR implementations are limited in their potential due to the lack of routinization. Any new technological innovation requires the physician support and willingness to learn about the system to move to the routinization phase of implementation. Hence, we draw from the literature on organization learning, individual learning, and routines to understand factors that influence EHR routinization

The Impact of Individual Learning on Electronic Health Record Routinization: An Empirical Study

Since the passage of the HITECH Act, adoption of electronic health records (EHR) has increased significantly EHR refers to an electronic version of a patient’s medical history. The adoption of EHR has potential to reduce medical errors, duplication of testing, and delays in treatment. However, current literature indicates that implementation of EHR is not resulting in the automatic routinization of EHR. Routinization refers to the notion that truly successful technological innovations are no longer perceived as being new or out-of-the-ordinary. The complexity of EHRs allow individual users to use these systems at different levels of sophistication. Research shows that healthcare professionals are using non-standard ways to use or circumvent the EHR to complete their work and are limited in EHR systems use. Further, although workarounds may seem necessary to physicians and are not perceived to be problematic, they can pose a threat to patient safety and hinder the potential benefits. Hence, we argue the EHR implementations are limited in their potential due to the lack of routinization. Any new technological innovation requires the physician support and willingness to learn about the system to move to the routinization phase of implementation. Hence, we draw from the literature on organization learning, individual learning, and routines to understand factors that influence EHR routinization