Medication decision-making for patients with renal insufficiency in inpatient and outpatient care at a US Veterans Affairs Medical Centre: a qualitative, cognitive task analysis.

BackgroundMany studies identify factors that contribute to renal prescribing errors, but few examine how healthcare professionals (HCPs) detect and recover from an error or potential patient safety concern. Knowledge of this information could inform advanced error detection systems and decision support tools that help prevent prescribing errors.ObjectiveTo examine the cognitive strategies that HCPs used to recognise and manage medication-related problems for patients with renal insufficiency.DesignHCPs submitted documentation about medication-related incidents. We then conducted cognitive task analysis interviews. Qualitative data were analysed inductively.SettingInpatient and outpatient facilities at a major US Veterans Affairs Medical Centre.ParticipantsPhysicians, nurses and pharmacists who took action to prevent or resolve a renal-drug problem in patients with renal insufficiency.OutcomesEmergent themes from interviews, as related to recognition of renal-drug problems and decision-making processes.ResultsWe interviewed 20 HCPs. Results yielded a descriptive model of the decision-making process, comprised of three main stages: detect, gather information and act. These stages often followed a cyclical path due largely to the gradual decline of patients' renal function. Most HCPs relied on being vigilant to detect patients' renal-drug problems rather than relying on systems to detect unanticipated cues. At each stage, HCPs relied on different cognitive cues depending on medication type: for renally eliminated medications, HCPs focused on gathering renal dosing guidelines, while for nephrotoxic medications, HCPs investigated the need for particular medication therapy, and if warranted, safer alternatives.ConclusionsOur model is useful for trainees so they can gain familiarity with managing renal-drug problems. Based on findings, improvements are warranted for three aspects of healthcare systems: (1) supporting the cyclical nature of renal-drug problem management via longitudinal tracking mechanisms, (2) providing tools to alleviate HCPs' heavy reliance on vigilance and (3) supporting HCPs' different decision-making needs for renally eliminated versus nephrotoxic medications

Examining the Relationship between Clinical Decision Support and Performance Measurement

In concept and practice, clinical decision support (CDS) and performance measurement represent distinct approaches to organizational change, yet these two organizational processes are interrelated. We set out to better understand how the relationship between the two is perceived, as well as how they jointly influence clinical practice. To understand the use of CDS at benchmark institutions, we conducted semistructured interviews with key managers, information technology personnel, and clinical leaders during a qualitative field study. Improved performance was frequently cited as a rationale for the use of clinical reminders. Pay-for-performance efforts also appeared to provide motivation for the use of clinical reminders. Shared performance measures were associated with shared clinical reminders. The close link between clinical reminders and performance measurement causes these tools to have many of the same implementation challenges

Redesign of a computerized clinical reminder for colorectal cancer screening: a human-computer interaction evaluation

<p>Abstract</p> <p>Background</p> <p>Based on barriers to the use of computerized clinical decision support (CDS) learned in an earlier field study, we prototyped design enhancements to the Veterans Health Administration's (VHA's) colorectal cancer (CRC) screening clinical reminder to compare against the VHA's current CRC reminder.</p> <p>Methods</p> <p>In a controlled simulation experiment, 12 primary care providers (PCPs) used prototypes of the current and redesigned CRC screening reminder in a within-subject comparison. Quantitative measurements were based on a usability survey, workload assessment instrument, and workflow integration survey. We also collected qualitative data on both designs.</p> <p>Results</p> <p>Design enhancements to the VHA's existing CRC screening clinical reminder positively impacted aspects of usability and workflow integration but not workload. The qualitative analysis revealed broad support across participants for the design enhancements with specific suggestions for improving the reminder further.</p> <p>Conclusions</p> <p>This study demonstrates the value of a human-computer interaction evaluation in informing the redesign of information tools to foster uptake, integration into workflow, and use in clinical practice.</p

Evaluating a Modular Decision Support Application For Colorectal Cancer Screening

BACKGROUND: There is a need for health information technology evaluation that goes beyond randomized controlled trials to include consideration of usability, cognition, feedback from representative users, and impact on efficiency, data quality, and clinical workflow. This article presents an evaluation illustrating one approach to this need using the Decision-Centered Design framework. OBJECTIVE: To evaluate, through a Decision-Centered Design framework, the ability of the Screening and Surveillance App to support primary care clinicians in tracking and managing colorectal cancer testing. METHODS: We leveraged two evaluation formats, online and in-person, to obtain feedback from a range primary care clinicians and obtain comparative data. Both the online and in-person evaluations used mock patient data to simulate challenging patient scenarios. Primary care clinicians responded to a series of colorectal cancer-related questions about each patient and made recommendations for screening. We collected data on performance, perceived workload, and usability. Key elements of Decision-Centered Design include evaluation in the context of realistic, challenging scenarios and measures designed to explore impact on cognitive performance. RESULTS: Comparison of means revealed increases in accuracy, efficiency, and usability and decreases in perceived mental effort and workload when using the Screening and Surveillance App. CONCLUSION: The results speak to the benefits of using the Decision-Centered Design approach in the analysis, design, and evaluation of Health Information Technology. Furthermore, the Screening and Surveillance App shows promise for filling decision support gaps in current electronic health records

Paper Persistence and Computer-based Workarounds with the Electronic Health Record in Primary Care

With the United States national goal and incentive program to transition from paper to electronic health records (EHRs), healthcare organizations are increasingly implementing EHRs and other related health information technology (IT). However, in institutions which have long adopted these computerized systems, such as the Veterans Health Administration, healthcare workers continue to rely on paper to complete their work. Furthermore, insufficient EHR design also results in computer-based workarounds. Using direct observation with opportunistic interviewing, we investigated the use of paper- and computer-based workarounds to the EHR with a multi-site study of 54 healthcare workers, including primary care providers, nurses, and other healthcare staff. Our analysis revealed several paper- and computer-based workarounds to the VA’s EHR. These workarounds, including clinician-designed information tools, provide evidence for how to enhance the design of the EHR to better support the needs of clinicians

Persuasive health educational materials for colorectal cancer screening

This paper describes an effort to design and evaluate persuasive educational materials for colorectal cancer (CRC) screening. Although CRC screening is highly effective, screening rates in the US remain low. Educational materials represent one strategy for educating patients about screening options and increasing openness to screening. We developed a one-page brochure, leveraging factual information from the Centers for Disease Control and Prevention (CDC) and national guidelines, and strategies for persuasion from the human factors and behavioral economics literatures. We evaluated the resulting brochure with adults over the age of 50. Findings suggest that the educational brochure increases knowledge of CRC and screening options, and increases openness to screening. Furthermore, no significant difference was found between the new one-page brochure and an existing multi-page Screen for Life brochure recommended by the CDC. We interpret these findings as indication that the more practical and potentially less intimidating one-page brochure is as effective as the existing multi-page Screen for Life brochure

Information Needs and Requirements for Decision Support in Primary Care: An Analysis of Chronic Pain Care

Decision support system designs often do not align with the information environments in which clinicians work. These work environments may increase Clinicians’ cognitive workload and harm their decision making. The objective of this study was to identify information needs and decision support requirements for assessing, diagnosing, and treating chronic noncancer pain in primary care. We conducted a qualitative study involving 30 interviews with 10 primary care clinicians and a subsequent multidisciplinary systems design workshop. Our analysis identified four key decision requirements, eight clinical information needs, and four decision support design seeds. Our findings indicate that clinicians caring for chronic pain need decision support that aggregates many disparate information elements and helps them navigate and contextualize that information. By attending to the needs identified in this study, decision support designers may improve Clinicians’ efficiency, reduce mental workload, and positively affect patient care quality and outcomes

Applied cognitive task analysis (ACTA): A practitioner's toolkit for understanding cognitive task demands

Cognitive task analysis (CTA) is a set of methods for identifying cognitive skills, or mental demands, needed to perform a task proficiently. The product of the task analysis can be used to inform the design of interfaces and training systems. However, CTA is resource intensive and has previously been of limited use to design practitioners. A streamlined method of CTA, Applied Cognitive Task Analysis (ACTA), is presented in this paper. ACTA consists of three interview methods that help the practitioner to extract information about the cognitive demands and skills required for a task. ACTA also allows the practitioner to represent this information in a format that will translate more directly into applied products, such as improved training scenarios or interface recommendations. This paper will describe the three methods, an evaluation study conducted to assess the usability and usefulness of the methods, and some directions for future research for making cognitive task analysis accessible to practitioners. ACTA techniques were found to be easy to use, flexible, and to provide clear output. The information and training materials developed based on ACTA interviews were found to be accurate and important for training purposes