Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems

Importance: The indication (reason for use) for a medication is rarely included on prescriptions despite repeated recommendations to do so. One barrier has been the way existing electronic prescribing systems have been designed. Objective: To evaluate, in comparison with the prescribing modules of 2 leading electronic health record prescribing systems, the efficiency, error rate, and satisfaction with a new computerized provider order entry prototype for the outpatient setting that allows clinicians to initiate prescribing using the indication. Design, Setting, and Participants: This quality improvement study used usability tests requiring internal medicine physicians, residents, and physician assistants to enter prescriptions electronically, including indication, for 8 clinical scenarios. The tool order assignments were randomized and prescribers were asked to use the prototype for 4 of the scenarios and their usual system for the other 4. Time on task, number of clicks, and order details were captured. User satisfaction was measured using posttask ratings and a validated system usability scale. The study participants practiced in 2 health systems\u27 outpatient practices. Usability tests were conducted between April and October of 2017. Main Outcomes and Measures: Usability (efficiency, error rate, and satisfaction) of indications-based computerized provider order entry prototype vs the electronic prescribing interface of 2 electronic health record vendors. Results: Thirty-two participants (17 attending physicians, 13 residents, and 2 physician assistants) used the prototype to complete 256 usability test scenarios. The mean (SD) time on task was 1.78 (1.17) minutes. For the 20 participants who used vendor 1\u27s system, it took a mean (SD) of 3.37 (1.90) minutes to complete a prescription, and for the 12 participants using vendor 2\u27s system, it took a mean (SD) of 2.93 (1.52) minutes. Across all scenarios, when comparing number of clicks, for those participants using the prototype and vendor 1, there was a statistically significant difference from the mean (SD) number of clicks needed (18.39 [12.62] vs 46.50 [27.29]; difference, 28.11; 95% CI, 21.47-34.75; P \u3c .001). For those using the prototype and vendor 2, there was also a statistically significant difference in number of clicks (20.10 [11.52] vs 38.25 [19.77]; difference, 18.14; 95% CI, 11.59-24.70; P \u3c .001). A blinded review of the order details revealed medication errors (eg, drug-allergy interactions) in 38 of 128 prescribing sessions using a vendor system vs 7 of 128 with the prototype. Conclusions and Relevance: Reengineering prescribing to start with the drug indication allowed indications to be captured in an easy and useful way, which may be associated with saved time and effort, reduced medication errors, and increased clinician satisfaction

Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems

Importance: The indication (reason for use) for a medication is rarely included on prescriptions despite repeated recommendations to do so. One barrier has been the way existing electronic prescribing systems have been designed. Objective: To evaluate, in comparison with the prescribing modules of 2 leading electronic health record prescribing systems, the efficiency, error rate, and satisfaction with a new computerized provider order entry prototype for the outpatient setting that allows clinicians to initiate prescribing using the indication. Design, Setting, and Participants: This quality improvement study used usability tests requiring internal medicine physicians, residents, and physician assistants to enter prescriptions electronically, including indication, for 8 clinical scenarios. The tool order assignments were randomized and prescribers were asked to use the prototype for 4 of the scenarios and their usual system for the other 4. Time on task, number of clicks, and order details were captured. User satisfaction was measured using posttask ratings and a validated system usability scale. The study participants practiced in 2 health systems\u27 outpatient practices. Usability tests were conducted between April and October of 2017. Main Outcomes and Measures: Usability (efficiency, error rate, and satisfaction) of indications-based computerized provider order entry prototype vs the electronic prescribing interface of 2 electronic health record vendors. Results: Thirty-two participants (17 attending physicians, 13 residents, and 2 physician assistants) used the prototype to complete 256 usability test scenarios. The mean (SD) time on task was 1.78 (1.17) minutes. For the 20 participants who used vendor 1\u27s system, it took a mean (SD) of 3.37 (1.90) minutes to complete a prescription, and for the 12 participants using vendor 2\u27s system, it took a mean (SD) of 2.93 (1.52) minutes. Across all scenarios, when comparing number of clicks, for those participants using the prototype and vendor 1, there was a statistically significant difference from the mean (SD) number of clicks needed (18.39 [12.62] vs 46.50 [27.29]; difference, 28.11; 95% CI, 21.47-34.75; P \u3c .001). For those using the prototype and vendor 2, there was also a statistically significant difference in number of clicks (20.10 [11.52] vs 38.25 [19.77]; difference, 18.14; 95% CI, 11.59-24.70; P \u3c .001). A blinded review of the order details revealed medication errors (eg, drug-allergy interactions) in 38 of 128 prescribing sessions using a vendor system vs 7 of 128 with the prototype. Conclusions and Relevance: Reengineering prescribing to start with the drug indication allowed indications to be captured in an easy and useful way, which may be associated with saved time and effort, reduced medication errors, and increased clinician satisfaction

Honoring Patient Do Not Resuscitate Wishes and Reducing Harm During Transitions of Care: A Quality Improvement Project

Objectives: The quality improvement project objectives were to honor documented Do Not Resuscitate wishes in emergency departments by examining and improving workflow during primary care to emergency department transitions. A location for advance care planning documentations was designated for advanced directives, yet not utilized. Methods: Mixed method, pre-/post-comparison, and thematic design examined clinicians and patients in a primary care office and two emergency departments in a Midwest healthcare system. Data was collected from patient records, clinician surveys, and observation of workflow. Descriptive statistics, frequency counts and non-parametric tests were used to analyze data. Results: Patient charts were audited (N=261 [pre=124; post=137]), mean age 79.2 years, 59% female. Clinician surveys included 32 emergency department providers (30=pre; 2=post) and 59 registered nurses (38=pre; 21=post). Patient chart audit (N=137) found 97% had a primary care code status with 2.9% in emergency department records. Provider (mean 2.93) and registered nurse (mean 3.14) moral distress was moderate. Pre/post barriers to discuss advanced directives increased from 80.2% to 100%; comfort discussing advanced directives improved from 43.2% to 100%; and providers (13.3-100%) and registered nurses (3-19%) were more aware of where to document advanced directives. Conclusions: Gaps in care placed patients with Do Not Resuscitate at risk for harm due to challenges with documentation. Post-implementation knowledge improved yet workflow and placement of Do Not Resuscitate orders in the record did not change. A clinically significant improvement in clinician knowledge of patient safety and location of advance care planning documents may lead to improved care

Taking Note: A Design Solution for Physician Documentation to Balance the Benefits of Handwritten Notes and Electronic Health Records

Master of Design in Integrative DesignUniversity of Michiganhttps://deepblue.lib.umich.edu/bitstream/2027.42/136865/1/THo_2017_MDes-Thesis.pd

Identifying Physicians’ User Experience (UX) Pain Points in Using Electronic Health Record (EHR) Systems

Healthcare institutions have migrated to online electronic documentation through the means of Electronic Health Record (EHR) systems. Physicians rely on these systems to support their various clinical work processes, such as entering clinical orders, reviewing essential clinical data, and making important medical decisions using reporting analytics. Although EHR systems appear to be useful and have known advantages over paper records, studies suggest there are persistent user interface design problems that may hinder physician productivity. The study focused on the research problem that EHR system designs create productivity problems for physician users who frequently report that system workflows are inefficient and do not map to their clinical process needs. Although researchers have examined EHR system adaptation and user interface design with various stakeholders, research is limited on the lived experiences of physicians who use the system. A few studies have focused on quantifying the factors that describe the phenomena of “meaningful use” of EHR systems. A qualitative approach to studying the phenomenon of physicians\u27 use of EHR systems is understudied and is relevant to investigate given EHR systems have become commonplace tools in clinical settings. An interpretive phenomenological analysis (IPA) study was conducted with the goal to discover what emergency room physicians describe as the pain points of their user experiences with EHR systems, which may include many different experiences to be uncovered, and their perspectives about how they manage the difficulty of system tasks and demands. Eight participants who represented a purposeful sample were recruited from one hospital in the Southeast region of the United States and participated in semi-structured interviews with open-ended questions. The data derived from the personal lived experiences of the participants were reviewed and analyzed through a step-by-step analytical process to develop five super-ordinate themes: Historical Chart Review, Inadequate Note Documentation, Difficult Order Entry, Patient Throughput Barriers, and Poor System Performance. The findings reveal consistencies with previous research that suggests physicians experience mental burden and burnout using EHR systems due to task complexity, task demand, and inefficiencies of system design. The findings have multiple implications for information technology (IT) system designers, healthcare administrators, and physician end users. This study provides future research opportunities to investigate the experiences of individuals who work in a different specialized area of the hospital, such as the intensive care unit (ICU)

Physician Satisfaction and Usability of Clinical Decision Support Tools in an Academic Medical Center’s Electronic Patient Record

Despite the available research on the benefits, capabilities, and implementation barriers and challenges of electronic Clinical Decision Support (CDS) tools physicians are still reluctant to utilize them. There are multiple studies that demonstrate limited buy-in and overall disinclination to use them however few studies evaluate physician satisfaction with CDS tools and the usability factors that may be associated with increasing satisfaction. The Questionnaire for User Interaction Satisfaction (QUIS) was disseminated to all P4 Residents and P4 Physician Hospitalists who routinely use the academic medical center’s electronic medical record (EMR). Overall user satisfaction was most correlated with the Layout/Screen Design and System Learning usability factors. It was unexpectedly not associated with Capabilities. The development of these tools should consider and encourage practices that invite analysts and physicians to collaborate on the principles and standards to guide design. Studies that focus on human-computer interactions can assist with the development of meaningful design strategies that will increase physician satisfaction resulting in increased physician usage of available CDS tools. Since CDS tools are often implemented to assist physicians with effective decision making to improve patient outcomes, ongoing efforts are needed to foster any long term successes of CDS tools

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