Clinical benefits of electronic health record use: national findings

The Effect of Medical Scribes in Emergency Departments: A Systematic Review

BACKGROUND

Integrating medical scribes with clinicians has been suggested to improve access, quality of care, enhance patient/clinician satisfaction, and increase productivity revenue.

OBJECTIVE

Conduct a systematic review to evaluate the effects of medical scribes in emergency departments.

METHODS

Electronic databases from 2010 through December 2019. Two individuals independently reviewed study eligibility, rated risk of bias, and determined overall certainty of evidence. Data abstracted included study and population characteristics, outcomes (efficiency, patient or clinician satisfaction, financial productivity, documentation quality, cost, and training time), and the effect of compensation structure, qualifications, duties, and setting on outcomes.

RESULTS

Twenty studies (18 observational) were included; 12 from two institutions. All utilized in-person rather than virtual scribes. Fifteen were rated as serious or critical risk of bias; five were rated moderate. Findings indicate that scribes may increase patients seen per day and decrease length of stay; however, effects were small and may vary by setting and outcome measured (low certainty). Scribes may increase financial productivity; however, costs associated with developing, implementing, and maintaining scribe programs were not adequately reported. Results were mixed for door-to-room or door-to-provider time, patients left without being seen, and patient/clinician satisfaction. No studies examined the effects of scribes based on compensation structure, qualifications or duties.

CONCLUSIONS

Although information quality, quantity, and applicability are limited, in-person medical scribes may improve emergency department efficiency and financial productivity. There was no information on virtual scribes. There was little information on patient or clinician satisfaction, scribe documentation quality, or whether results vary by in-house vs. contracted hiring and training.

Electronic Health Record Use in Swiss Nursing Homes and Its Association With Implicit Rationing of Nursing Care Documentation: Multicenter Cross-sectional Survey Study

BACKGROUND

Nursing homes (NHs) are increasingly implementing electronic health records (EHRs); however, little information is available on EHR use in NH settings. It remains unclear how care workers perceive its safety, quality, and efficiency, and whether EHR use might ease the burden of documentation, thereby reducing its implicit rationing.

OBJECTIVE

This study aims to describe nurses' perceptions regarding the usefulness of the EHR system and whether sufficient numbers of computers are available in Swiss NHs, and to explore the system's association with implicit rationing of nursing care documentation.

METHODS

This was a multicenter cross-sectional study using survey data from the Swiss Nursing Homes Human Resources Project 2018. It includes a convenience sample of 107 NHs, 302 care units, and 1975 care workers (ie, registered nurses and licensed practical nurses) from Switzerland's German- and French-speaking regions. Care workers completed questionnaires assessing the level of implicit rationing of nursing care documentation, their perceptions of the EHR system's usefulness and of how sufficient the number of available computers was, staffing and resource adequacy, leadership ability, and teamwork and safety climate. For analysis, we applied generalized linear mixed models, including individual-level nurse survey data and data on unit and facility characteristics.

RESULTS

Overall, the care workers perceived the EHR systems as useful; ratings ranged from 69.42% (1362/1962; guarantees safe care and treatment) to 78.32% (1535/1960; allows quick access to relevant information on the residents). However, less than half (914/1961, 46.61%) of the care workers reported sufficient computers on their unit to allow timely documentation. Half of the care workers responded that they sometimes or often had to ration the documentation of care. After adjusting for work environment factors and safety and teamwork climate, both higher care worker ratings of the EHR system's usefulness (β=-.12; 95% CI -0.17 to -0.06) and sufficient numbers of computers (β=-.09; 95% CI -0.12 to -0.06) were consistently associated with lower implicit rationing of nursing care documentation.

CONCLUSIONS

Both the usefulness of the EHR system and the number of computers available were important explanatory factors for care workers leaving care activities (eg, developing or updating nursing care plans) unfinished. NH managers should carefully select and implement their information technology infrastructure with greater involvement and attention to the needs of their care workers and residents. Further research is needed to develop and implement user-friendly information technology infrastructure in NHs and to evaluate their impact on care processes as well as resident and care worker outcomes.

A Bespoke Electronic Health Record for Epilepsy Care (EpiToMe): Development and Qualitative Evaluation

BACKGROUND

While electronic health records (EHR) bring various benefits to health care, EHR systems are often criticized as cumbersome to use, failing to fulfill the promise of improved health care delivery with little more than a means of meeting regulatory and billing requirements. EHR has also been recognized as one of the contributing factors for physician burnout.

OBJECTIVE

Specialty-specific EHR systems have been suggested as an alternative approach that can potentially address challenges associated with general-purpose EHRs. We introduce the Epilepsy Tracking and optimized Management engine (EpiToMe), an exemplar bespoke EHR system for epilepsy care. EpiToMe uses an agile, physician-centered development strategy to optimize clinical workflow and patient care documentation. We present the design and implementation of EpiToMe and report the initial feedback on its utility for physician burnout.

METHODS

Using collaborative, asynchronous data capturing interfaces anchored to a domain ontology, EpiToMe distributes reporting and documentation workload among technicians, clinical fellows, and attending physicians. Results of documentation are transmitted to the parent EHR to meet patient care requirements with a push of a button. An HL7 (version 2.3) messaging engine exchanges information between EpiToMe and the parent EHR to optimize clinical workflow tasks without redundant data entry. EpiToMe also provides live, interactive patient tracking interfaces to ease the burden of care management.

RESULTS

Since February 2019, 15,417 electroencephalogram reports, 2635 Epilepsy Monitoring Unit daily reports, and 1369 Epilepsy Monitoring Unit phase reports have been completed in EpiToMe for 6593 unique patients. A 10-question survey was completed by 11 (among 16 invited) senior clinical attending physicians. Consensus was found that EpiToMe eased the burden of care documentation for patient management, a contributing factor to physician burnout.

CONCLUSIONS

EpiToMe offers an exemplar bespoke EHR system developed using a physician-centered design and latest advancements in information technology. The bespoke approach has the potential to ease the burden of care management in epilepsy. This approach is applicable to other clinical specialties.

Meaningful Use of Electronic Health Records and Ambulatory Healthcare Quality Measures

Introduction

Electronic Health Record (EHR) adoption rates for office-based physicians doubled between 2008 and 2015, from 42% to 89%, and more than 60% of all office-based physicians achieved meaningful use by 2016. The US government has paid billions of dollars in incentives to promote EHR meaningful use. Nonetheless, evidence linking EHR meaningful use to quality measures improvements is limited.

Objective

This study aims to examine the relationship between EHR meaningful use and capabilities among four quality measures in an ambulatory healthcare setting.

Study design

A cross-sectional study design of the 2015-2016 National Ambulatory Medical Care Survey dataset.

Methods

We used adjusted multivariate regression models to examine associations between (a) EHR meaningful use and (b) 10 EHR-computerized capabilities, with four quality measures (blood pressure screening, tobacco use screening, obesity screening, and obesity education).

Results

We analyzed 30,787 office visits, representing an annual estimate of 680 million national office visits. Results showed that 95% of visits were to offices meeting EHR meaningful use criteria. We found one positive association between EHR meaningful use and obesity screening (OR= 3.5, 95% CI [1.742-6.917]). We also found eight positive associations between EHR capabilities and three quality measures (screening for blood pressure and obesity, and obesity education). These associations included five EHR-computerized capabilities: “record patient problem list”, “view lab results”, “Reminders for interventions/screening”, “Order lab results” and “Recording clinical notes”. No EHR capability was associated with screening for tobacco use.

Conclusions

We looked at a handful of screening-oriented quality measures in ambulatory healthcare and found limited associations with EHR meaningful use but multiple positively significant associations with EHR capabilities. Although EHR meaningful use has become more commonly used, offering substantial administrative efficiency over paper records, current patterns of EHR meaningful use do not always appear to translate into a better quality of care in physician offices. However, quality measures used represent limited procedures for a handful of specific conditions and not the overall healthcare aspect.

Health Information Technology–Related Wrong-Patient Errors: Context is Critical

Health information technology (HIT) provides many benefits, but also facilitates certain types of errors, such as wrong-patient errors in which one patient is mistaken for another. These errors can have serious patient safety consequences and there has been significant effort to mitigate the risk of these errors through national patient safety goals, in-depth research, and the development of safety toolkits. Nonetheless, these errors persist. We analyzed 1,189 patient safety event reports using a safety science and resilience engineering approach, which focuses on identifying processes to discover errors before they reach the patient so these processes can be expanded. We analyzed the general care processes in which wrong-patient errors occurred, the clinical process step during which the error occurred and was discovered, and whether the error reached the patient. For those errors that reached the patient, we analyzed the impact on the patient, and for those that did not reach the patient, we analyzed how the error was caught. Our results demonstrate that errors occurred across multiple general care process areas, with 24.4% of wrong-patient error events reaching the patient. Analysis of clinical process steps indicated that most errors occurred during ordering/prescribing (n=498; 41.9%) and most errors were discovered during review of information (n=286; 24.1%). Patients were primarily impacted by inappropriate medication administration (n=110; 37.9%) and the wrong test or procedure being performed (n=65; 22.4%). When errors were caught before reaching the patient, this was primarily because of nurses, technicians, or other healthcare staff (n=303; 60.5%). The differences between the general care processes can inform wrong-patient error risk mitigation strategies. Based on these analyses and the broader literature, this study offers recommendations for addressing wrong-patient errors using safety science and resilience engineering, and it provides a unique lens for evaluating HIT wrong-patient errors.

Perceptions of healthcare professionals about the adoption and use of EHR in Gulf Cooperation Council countries: a systematic review

Introduction

Electronic health records (EHRs) can improve the quality and safety of care. However, the adoption and use of the EHR is influenced by several factors, including users’ perception.

Objectives

To undertake a systematic review of the literature to understand healthcare professionals’ perceptions about the adoption and use of EHRs in Gulf Cooperation Council (GCC) countries in order to influence the implementation strategies, training programme and policy development in the GCC region.

Method

A systematic literature search was undertaken on seven online databases to identify articles published between January 2006 and December 2017 examining healthcare professionals’ perception towards the adoption and use of EHR in the Gulf context.

Results

The fourteen articles included in this review identified both positive and negative perceptions of the role of EHR in healthcare. The positive perceptions included EHR benefits, such as improvements to work efficiency, quality of care, communication and access to patient data. Conversely, the negative perceptions were associated with challenges or risks of adopting an EHR, such as disruption of provider–patient communication, privacy and security concerns and high initial costs. The perceptions were influenced by personal factors (eg, age, occupation and computer literacy) and system factors (perceived usefulness and perceived ease of use).

Conclusion

Positive perceptions of EHRs by the healthcare professionals could facilitate the adoption of this technology in the Gulf region, particularly when barriers are addressed early. Negative perceptions may inform change management strategies during adoption and implementation. The perceptions should be further evaluated from a technology acceptance perspective.

Effects of Electronic Health Record Implementation and Barriers to Adoption and Use: A Scoping Review and Qualitative Analysis of the Content

Despite the great advances in the field of electronic health records (EHRs) over the past 25 years, implementation and adoption challenges persist, and the benefits realized remain below expectations. This scoping review aimed to present current knowledge about the effects of EHR implementation and the barriers to EHR adoption and use. A literature search was conducted in PubMed, Web of Science, IEEE Xplore Digital Library and ACM Digital Library for studies published between January 2005 and May 2020. In total, 7641 studies were identified of which 142 met the criteria and attained the consensus of all researchers on inclusion. Most studies (n = 91) were published between 2017 and 2019 and 81 studies had the United States as the country of origin. Both positive and negative effects of EHR implementation were identified, relating to clinical work, data and information, patient care and economic impact. Resource constraints, poor/insufficient training and technical/educational support for users, as well as poor literacy and skills in technology were the identified barriers to adoption and use that occurred frequently. Although this review did not conduct a quality analysis of the included papers, the lack of uniformity in the use of EHR definitions and detailed contextual information concerning the study settings could be observed.

Advanced Health Information Technologies to Engage Parents, Clinicians, and Community Nutritionists in Coordinating Responsive Parenting Care: Descriptive Case Series of the Women, Infants, and Children Enhancements to Early Healthy Lifestyles for Baby (WEE Baby) Care Randomized Controlled Trial

BACKGROUND

Socioeconomically disadvantaged newborns receive care from primary care providers (PCPs) and Women, Infants, and Children (WIC) nutritionists. However, care is not coordinated between these settings, which can result in conflicting messages. Stakeholders support an integrated approach that coordinates services between settings with care tailored to patient-centered needs.

OBJECTIVE

This analysis describes the usability of advanced health information technologies aiming to engage parents in self-reporting parenting practices, integrate data into electronic health records to inform and facilitate documentation of provided responsive parenting (RP) care, and share data between settings to create opportunities to coordinate care between PCPs and WIC nutritionists.

METHODS

Parents and newborns (dyads) who were eligible for WIC care and received pediatric care in a single health system were recruited and randomized to a RP intervention or control group. For the 6-month intervention, electronic systems were created to facilitate documentation, data sharing, and coordination of provided RP care. Prior to PCP visits, parents were prompted to respond to the Early Healthy Lifestyles (EHL) self-assessment tool to capture current RP practices. Responses were integrated into the electronic health record and shared with WIC. Documentation of RP care and an 80-character, free-text comment were shared between WIC and PCPs. A care coordination opportunity existed when the dyad attended a WIC visit and these data were available from the PCP, and vice versa. Care coordination was demonstrated when WIC or PCPs interacted with data and documented RP care provided at the visit.

RESULTS

Dyads (N=131) attended 459 PCP (3.5, SD 1.0 per dyad) and 296 WIC (2.3, SD 1.0 per dyad) visits. Parents completed the EHL tool prior to 53.2% (244/459) of PCP visits (1.9, SD 1.2 per dyad), PCPs documented provided RP care at 35.3% (162/459) of visits, and data were shared with WIC following 100% (459/459) of PCP visits. A WIC visit followed a PCP visit 50.3% (231/459) of the time; thus, there were 1.8 (SD 0.8 per dyad) PCP to WIC care coordination opportunities. WIC coordinated care by documenting RP care at 66.7% (154/231) of opportunities (1.2, SD 0.9 per dyad). WIC visits were followed by a PCP visit 58.9% (116/197) of the time; thus, there were 0.9 (SD 0.8 per dyad) WIC to PCP care coordination opportunities. PCPs coordinated care by documenting RP care at 44.0% (51/116) of opportunities (0.4, SD 0.6 per dyad).

CONCLUSIONS

Results support the usability of advanced health information technology strategies to collect patient-reported data and share these data between multiple providers. Although PCPs and WIC shared data, WIC nutritionists were more likely to use data and document RP care to coordinate care than PCPs. Variability in timing, sequence, and frequency of visits underscores the need for flexibility in pragmatic studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03482908; https://clinicaltrials.gov/ct2/show/NCT03482908.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12887-018-1263-z.

Perceived Value of Electronic Medical Records in Community Health Services: A National Cross-Sectional Survey of Primary Care Workers in Mainland China

Objective: To evaluate the degree to which electronic medical records (EMRs) were used in primary care and the value of EMRs as perceived by primary care workers in China. Methods: A cross-sectional survey was conducted on 2719 physicians (n = 2213) and nurses (n = 506) selected from 462 community health centres across all regions of mainland China except for Tibet. Regional differences in the responses regarding the functionality of existing EMR systems and the perceived value of EMRs were examined using Chi-square tests and ordinal regression analyses. Results: Less than 59% of the community health centres had adopted EMRs. More than 89% of the respondents believed that it was necessary to adopt EMRs in primary care. Of the existing EMR systems, 50% had access to telehealth support for laboratory, imaging or patient consultation services. Only 38.4% captured data that met all task needs and 35.4% supported referral arrangements. “Management of chronic conditions” was voted (66%) as the top preferred feature of EMRs. Higher levels of recognition of the value of EMRs were found in the relatively more developed eastern region compared with their counterparts in other regions. Conclusions: Rapid EMR adoption in primary care is evident in mainland China. The low level of functionality in data acquisition and referral arrangements runs counter to the requirements for “management of chronic conditions”, the most preferred feature of EMRs in primary care. Regional disparities in the realised value of EMRs in primary care deserve policy attention.

Optimizing the Cognitive Space of Nursing Work Through Electronic Medical Records

The incorporation of electronic medical records into nursing practice highlights the need to facilitate communication among nurses. The extensive use of information suggests that electronic medical records should be considered in the cognitive workspace to manage information and facilitate communication. The purpose of this study was to construct an integrative model to explain the role of electronic medical records in the cognitive workspace. This work is grounded in the Theory of Swift and Even Flow and Distributive Cognition. The Distributive Cognitive model views the workplace as a cognitive system, such that cognitive processes do not occur in individual clinicians, but as a collaborative effort among nurses. The Theory of Swift and Even Flow was used to explain the flow of information among nurses. We used a qualitative approach to gather data from nurses at local inpatient facilities. Seven focus groups among three facilities were completed (n = 34). A semistructured questionnaire guided the focus group sessions. The results suggest that electronic medical records contribute to the cognitive workspace by serving as a conduit for information to be collected and distributed. These systems may positively influence nursing care when the quality, quantity, and timeliness of information are optimized.

Factors Influencing Healthcare Professionals' Perception towards EHR/EMR Systems in Gulf Cooperation Council Countries: A Systematic Review

Electronic health and medical records are widely adopted in many healthcare settings worldwide to improve the quality of care. Users’ perception is a significant factor influencing the successful implementation and use of e-health technologies. This systematic review aimed to identify factors influencing the perceptions of healthcare professionals towards the adoption and use of electronic health and medical record systems to improve the quality of healthcare services in the countries of the Gulf Cooperation Council. We identified primary studies evaluating healthcare professionals’ perception towards electronic health records and/or electronic medical records in the Gulf region. Seven electronic databases, including Medline, CINAHL, Informit Health Collection, Science Direct, ProQuest, PubMed, and Scopus were used to search for the relevant articles published between January 2007 and December 2016. Thirteen articles met the inclusion criteria and were included in this systematic review. Both individual and system-related factors were found to positively or negatively influence healthcare providers’ perceptions towards the systems. Understanding the impact of healthcare professionals’ perception of health information technology is important for policymakers involved in the implementation programs to ensure their success. Future studies should evaluate other individual characteristics such as age, gender, and profession of the healthcare providers on their perceptions towards e-health technologies.

Electronic medical records and health care promotion in Saudi Arabia

A few decades ago, the government of Saudi Arabia introduced electronic medical records (EMRs) in some health care facilities. However, the progress in adopting these systems on a national level was slow. In 2008, the Saudi Ministry of Health started an initiative to expand and optimize the use of EMRs in governmental health care institutions. However, some obstacles facing this ambitious plan remain, including negative attitudes of some health care professionals toward EMR systems. Other barriers include poor computer literacy, lack of system customization to hospital needs, and poor support and training from information technology (IT) personnel. Identifying and addressing these barriers is essential for the optimal application of EMR systems in all health care facilities. In this review, the author focused on the benefits of widespread adoption of EMRs in Saudi Arabia, the perceptions of health care professionals, and the challenges and barriers toward improved implementation of this technology.

Exploring the contributing factors to workarounds to the hospital information system in Malaysian hospitals

OBJECTIVES

The objective of this study was to identify the factors influencing workarounds to the Hospital Information System (HIS) in Malaysian government hospitals.

METHODS

Semi-structured interviews were conducted among 31 medical doctors in three Malaysian government hospitals on the implementation of the Total Hospital Information System (THIS) between March and May 2015. A thematic qualitative analysis was performed on the resultant data to deduce the relevant themes.

RESULTS

Five themes emerged as the factors influencing workarounds to the HIS: (a) typing skills, (b) system usability, (c) computer resources, (d) workload, and (e) time.

CONCLUSIONS

This study provided the key factors as to why doctors were involved in workarounds during the implementation of the HIS. It is important to understand these factors in order to help mitigate work practices that can pose a threat to patient safety.

Nutrition Information in Oncology - Extending the Electronic Patient-Record Data Set

Electronic health records (EHRs) present extensive patient information and may be used as a tool to improve health care. However, the oncology context presents a complex content that increases the difficulties of EHR application. This study aimed at developing openEHR-archetypes representing clinical concepts in cancer nutrition-care, as well as to develop an openEHR-template including the aforementioned archetypes. The study involved the following stages: 1) a thorough literature review, followed by an expert’s (nutrition guideline authors) survey, aiming to identify the main statements of published clinical guidelines on nutrition in cancer patients that were not included on the Clinical Knowledge Manager (CKM) repository; 2) modelling of the archetypes using the Ocean Archetype Software and submission to the CKM repository; 3) creating an example template with Template Designer; and 4) automatic conversion of the openEHR-template into a readily usable EHR using VCIntegrator. The clinical concepts (among 17 clinical concepts not yet available in the CKM repository) chosen for further development were: body composition, diet plan, dietary nutrients, dietary supplements, dietary intake assessment, and Malnutrition Screening Tool (MST). So far, four archetypes were accepted for review in the CKM repository and a template was created and converted into an EHR. This study designed new openEHR-archetypes for nutrition management in cancer patients. These archetypes can be included in EHR. Future studies are needed to assess their applicability in other areas and their practical impact on data quality, system interoperability and, ultimately, on clinical practice and research.

Barriers and Facilitators Associated with the Management of Aggressive and Disruptive Behaviour in Children: A Qualitative Study with Pediatricians

BACKGROUND

Aggressive and disruptive behaviours are frequently observed in children. Short-term use of antipsychotics with monitoring for adverse effects is recommended when first-line interventions fail (e.g. psychosocial therapies and psychostimulants for ADHD). This study aimed to understand the barriers and facilitators to behavioural change for the management of aggressive and disruptive behaviours by pediatricians.

METHODS

This was a qualitative study with twenty community-based pediatricians. An interview guide was developed to elicit beliefs associated with practice behaviours. We used thematic content analysis with the Theoretical Domains Framework to inform knowledge translation interventions, by helping to determine what behavioural barriers and facilitators to practice exist. Key domains which influenced behaviour were identified by evaluating the frequency of beliefs across interviews, conflicting beliefs, and the strength of beliefs impacting behaviour.

RESULTS

Pediatricians described evaluating the impact of aggressive and disruptive behaviours, attempting to determine their cause, and using an approach that prioritized psychosocial therapies and psychostimulants. Pediatricians reported that antipsychotics were effective but that they experienced anxiety about harms, and there was a need to accept the adverse effects as a trade-off for improved function. Discontinuing antipsychotics was problematic. Despite awareness of antipsychotic-induced movement disorders and metabolic effects, there were limitations in physician skills, knowledge and resources and social influences that were a barrier to routine implementation of recommended monitoring procedures.

CONCLUSIONS

This study identifies barriers and facilitators to evidence-based practice that can be used for knowledge translation interventions to ensure a high standard of care for children prescribed antipsychotics.

Clinical problem solving and social determinants of health: a descriptive study using unannounced standardized patients to directly observe how resident physicians respond to social determinants of health

Objectives While the need to address patients' social determinants of health (SDoH) is widely recognized, less is known about physicians' actual clinical problem-solving when it comes to SDoH. Do physicians include SDoH in their assessment strategy? Are SDoH incorporated into their diagnostic thinking and if so, do they document as part of their clinical reasoning? And do physicians directly address SDoH in their "solution" (treatment plan)? Methods We used Unannounced Standardized Patients (USPs) to assess internal medicine residents' clinical problem solving in response to a patient with asthma exacerbation and concern that her moldy apartment is contributing to symptoms - a case designed to represent a clear and direct link between a social determinant and patient health. Residents' clinical practices were assessed through a post-visit checklist and systematic chart review. Patterns of clinical problem solving were identified and then explored, in depth, through review of USP comments and history of present illness (HPI) and treatment plan documentation. Results Residents fell into three groups when it came to clinical problem-solving around a housing trigger for asthma: those who failed to ask about housing and therefore did not uncover mold as a potential trigger (neglectors – 21%; 14/68); those who asked about housing in negative ways that prevented disclosure and response (negative elicitors – 23%, 16/68); and those who elicited and explored the mold issue (full elicitors – 56%; 38/68) [corrected]. Of the full elicitors 53% took no further action, 26% only documented the mold; and 21% provided resources/referral. In-depth review of USP comments/explanations and residents' notes (HPI, treatment plan) revealed possible influences on clinical problem solving. Failure to ask about housing was associated with both contextual factors (rushed visit) and interpersonal skills (not fully engaging with patient) and with possible differences in attention ("known" vs. unknown/new triggers, usual symptoms vs. changes, not attending to relocation, etc.,). Use of close-ended questions often made it difficult for the patient to share mold concerns. Negative responses to sharing of housing information led to missing mold entirely or to the patient not realizing that the physician agreed with her concerns about mold. Residents who fully elicited the mold situation but did not take action seemed to either lack knowledge or feel that action on SDoH was outside their realm of responsibility. Those that took direct action to help the patient address mold appeared to be motivated by an enhanced sense of urgency. Conclusions Findings provide unique insight into residents' problem solving processes including external influences (e.g., time, distractions), the role of core communication and interpersonal skills (eliciting information, creating opportunities for patients to voice concerns, sharing clinical thinking with patients), how traditional cognitive biases operate in practice (premature closure, tunneling, and ascertainment bias), and the ways in which beliefs about expectancies and scope of practice may color clinical problem-solving strategies for addressing SDoH.

Scribes, EHRs, and Workflow Efficiencies in Allergy Practices

PURPOSE OF REVIEW

In the ever-changing healthcare system, along with new advancements in the field of allergy, the workflow for the allergist continues to evolve requiring more time spent doing non-clinical duties such as documentation and reviewing reimbursement challenges in the midst of busy clinics. The use of electronic medical records and medical scribes has emerged as tactics to aid the clinic's workflow and efficiency in the modern allergy and immunology clinic.

RECENT FINDINGS

The practicing allergist can implement various additional strategies in their office workflow to maximize and synthesize good medicine and good business. Optimal use of office staff, electronic health records, and various workflow efficiencies has been shown to improve job satisfaction and reduce physician burnout. By utilizing these methods and integrating them into their practices, allergists will be able to meet the demands of the healthcare system and still provide patients with evidence based, compassionate, and cost-effective care.

Requirements of Health Data Management Systems for Biomedical Care and Research: Scoping Review

BACKGROUND

Over the last century, disruptive incidents in the fields of clinical and biomedical research have yielded a tremendous change in health data management systems. This is due to a number of breakthroughs in the medical field and the need for big data analytics and the Internet of Things (IoT) to be incorporated in a real-time smart health information management system. In addition, the requirements of patient care have evolved over time, allowing for more accurate prognoses and diagnoses. In this paper, we discuss the temporal evolution of health data management systems and capture the requirements that led to the development of a given system over a certain period of time. Consequently, we provide insights into those systems and give suggestions and research directions on how they can be improved for a better health care system.

OBJECTIVE

This study aimed to show that there is a need for a secure and efficient health data management system that will allow physicians and patients to update decentralized medical records and to analyze the medical data for supporting more precise diagnoses, prognoses, and public insights. Limitations of existing health data management systems were analyzed.

METHODS

To study the evolution and requirements of health data management systems over the years, a search was conducted to obtain research articles and information on medical lawsuits, health regulations, and acts. These materials were obtained from the Institute of Electrical and Electronics Engineers, the Association for Computing Machinery, Elsevier, MEDLINE, PubMed, Scopus, and Web of Science databases.

RESULTS

Health data management systems have undergone a disruptive transformation over the years from paper to computer, web, cloud, IoT, big data analytics, and finally to blockchain. The requirements of a health data management system revealed from the evolving definitions of medical records and their management are (1) medical record data, (2) real-time data access, (3) patient participation, (4) data sharing, (5) data security, (6) patient identity privacy, and (7) public insights. This paper reviewed health data management systems based on these 7 requirements across studies conducted over the years. To our knowledge, this is the first analysis of the temporal evolution of health data management systems giving insights into the system requirements for better health care.

CONCLUSIONS

There is a need for a comprehensive real-time health data management system that allows physicians, patients, and external users to input their medical and lifestyle data into the system. The incorporation of big data analytics will aid in better prognosis or diagnosis of the diseases and the prediction of diseases. The prediction results will help in the development of an effective prevention plan.

ClinicNet: machine learning for personalized clinical order set recommendations

OBJECTIVE

This study assesses whether neural networks trained on electronic health record (EHR) data can anticipate what individual clinical orders and existing institutional order set templates clinicians will use more accurately than existing decision support tools.

MATERIALS AND METHODS

We process 57 624 patients worth of clinical event EHR data from 2008 to 2014. We train a feed-forward neural network (ClinicNet) and logistic regression applied to the traditional problem structure of predicting individual clinical items as well as our proposed workflow of predicting existing institutional order set template usage.

RESULTS

ClinicNet predicts individual clinical orders (precision = 0.32, recall = 0.47) better than existing institutional order sets (precision = 0.15, recall = 0.46). The ClinicNet model predicts clinician usage of existing institutional order sets (avg. precision = 0.31) with higher average precision than a baseline of order set usage frequencies (avg. precision = 0.20) or a logistic regression model (avg. precision = 0.12).

DISCUSSION

Machine learning methods can predict clinical decision-making patterns with greater accuracy and less manual effort than existing static order set templates. This can streamline existing clinical workflows, but may not fit if historical clinical ordering practices are incorrect. For this reason, manually authored content such as order set templates remain valuable for the purposeful design of care pathways. ClinicNet's capability of predicting such personalized order set templates illustrates the potential of combining both top-down and bottom-up approaches to delivering clinical decision support content.

CONCLUSION

ClinicNet illustrates the capability for machine learning methods applied to the EHR to anticipate both individual clinical orders and existing order set templates, which has the potential to improve upon current standards of practice in clinical order entry.

Electronic Health Record Implementation Findings at a Large, Suburban Health and Human Services Department

OBJECTIVE

Evaluate an electronic health record (EHR) implementation across a large public health department to better understand and improve implementation effectiveness of EHRs in public health departments.

DESIGN

A survey based on Consolidated Framework for Implementation Research constructs was administered to staff before and after implementation of an EHR.

SETTING

Large suburban county department of health and human services that provides clinical, behavioral, social, and oral health services.

PARTICIPANTS

Staff across 4 program areas completed the survey prior to EHR implementation (n = 331, June 2014) and 3 months post-EHR final implementation (n = 229, December 2015).

INTERVENTION

Electronic health record MAIN OUTCOME MEASURES:: Constructs were validated using confirmatory factor analysis and included information strengths and information gaps in the current environment; EHR impacts; ease of use; future use intentions; usefulness; knowledge of system; and training. Paired t tests and Wilcoxon signed rank tests of a matched sample were performed to compare the pre-/postrespondent scores.

RESULTS

A majority of user perceptions and expectations showed a significant (P < .05) decline 3 months postimplementation as compared with the baseline with variation by service area and construct. Staff perceived the EHR to be less useful and more complex, provide fewer benefits, and reduce information access shortly after implementation.

CONCLUSIONS

Electronic health records can benefit public health practices in many ways; however, public health departments will face significant challenges incorporating EHRs, which are typically designed for non-public health settings, into the public health workflow. Electronic health record implementation recommendations for health departments are provided. When implementing an EHR in a public health setting, health departments should provide extensive preimplementation training opportunities, including EHR training tailored to job roles, competencies, and tasks; assess usability and specific capabilities at a more granular level as part of procurement processes and consider using contracting language to facilitate usability, patient safety, and related evaluations to enhance effectiveness and efficiencies and make results public; apply standard terminologies, processes, and data structures across different health department service areas using common public health terminologies; and craft workforce communication campaigns that balance potential expected benefits with realistic expectations.

Effect of an Electronic Health Record Transition on the Provision of Recommended Well Child Services in Pediatric Primary Care Practices

We sought to determine the effect of transitioning between electronic health record (EHR) systems on the quality of preventive care in a large pediatric primary care network. To study this, we performed a retrospective chart analysis of 42 primary care practices from the Pediatric Physicians' Organization at Children's who transitioned EHRs. We reviewed 24 random encounters per week distributed evenly across 6 age categories before, during, and after a transition period. We reviewed encounter documentation for age-appropriate well child services, per American Academy of Pediatrics/Bright Futures guidelines. Logistic regression and statistical process control analysis were used. In the pretransition period, 84.5% of all recommended elements were documented versus 86.4% posttransition (P = .04). Documentation of age-appropriate anticipatory guidance showed significant positive change (69.0% to 80.2%, P = .005), but it was the only subdomain with a statistically significant increase. These increases suggest that EHR transitions have the opportunity to affect the delivery of preventive care.

Improving data sharing between acute hospitals in England: an overview of health record system distribution and retrospective observational analysis of inter-hospital transitions of care

OBJECTIVES

To determine the frequency of use and spatial distribution of health record systems in the English National Health Service (NHS). To quantify transitions of care between acute hospital trusts and health record systems to guide improvements to data sharing and interoperability.

DESIGN

Retrospective observational study using Hospital Episode Statistics.

SETTING

Acute hospital trusts in the NHS in England.

PARTICIPANTS

All adult patients resident in England that had one or more inpatient, outpatient or accident and emergency encounters at acute NHS hospital trusts between April 2017 and April 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

Frequency of use and spatial distribution of health record systems. Frequency and spatial distribution of transitions of care between hospital trusts and health record systems.

RESULTS

21 286 873 patients were involved in 121 351 837 encounters at 152 included trusts. 117 (77.0%) hospital trusts were using electronic health records (EHR). There was limited regional alignment of EHR systems. On 11 017 767 (9.1%) occasions, patients attended a hospital using a different health record system to their previous hospital attendance. 15 736 863 (73.9%) patients had two or more encounters with the included trusts and 3 931 255 (25.0%) of those attended two or more trusts. Over half (53.6%) of these patients had encounters shared between just 20 pairs of hospitals. Only two of these pairs of trusts used the same EHR system.

CONCLUSIONS

Each year, millions of patients in England attend two or more different hospital trusts. Most of the pairs of trusts that commonly share patients do not use the same record systems. This research highlights significant barriers to inter-hospital data sharing and interoperability. Findings from this study can be used to improve electronic health record system coordination and develop targeted approaches to improve interoperability. The methods used in this study could be used in other healthcare systems that face the same interoperability challenges.

Neurological Dashboards and Consultation Turnaround Time at an Academic Medical Center

BACKGROUND

Neurologists perform a significant amount of consultative work. Aggregative electronic health record (EHR) dashboards may help to reduce consultation turnaround time (TAT) which may reflect time spent interfacing with the EHR.

OBJECTIVES

This study was aimed to measure the difference in TAT before and after the implementation of a neurological dashboard.

METHODS

We retrospectively studied a neurological dashboard in a read-only, web-based, clinical data review platform at an academic medical center that was separate from our institutional EHR. Using our EHR, we identified all distinct initial neurological consultations at our institution that were completed in the 5 months before, 5 months after, and 12 months after the dashboard go-live in December 2017. Using log data, we determined total dashboard users, unique page hits, patient-chart accesses, and user departments at 5 months after go-live. We calculated TAT as the difference in time between the placement of the consultation order and completion of the consultation note in the EHR.

RESULTS

By April 30th in 2018, we identified 269 unique users, 684 dashboard page hits (median hits/user 1.0, interquartile range [IQR] = 1.0), and 510 unique patient-chart accesses. In 5 months before the go-live, 1,434 neurology consultations were completed with a median TAT of 2.0 hours (IQR = 2.5) which was significantly longer than during 5 months after the go-live, with 1,672 neurology consultations completed with a median TAT of 1.8 hours (IQR = 2.2; p = 0.001). Over the following 7 months, 2,160 consultations were completed and median TAT remained unchanged at 1.8 hours (IQR = 2.5).

CONCLUSION

At a large academic institution, we found a significant decrease in inpatient consult TAT 5 and 12 months after the implementation of a neurological dashboard. Further study is necessary to investigate the cognitive and operational effects of aggregative dashboards in neurology and to optimize their use.

The Impact of Medical Scribes on Patient Satisfaction in an Academic Otolaryngology Clinic

Objectives:

Evidence shows that scribes can improve provider efficiency and satisfaction in several settings, but is mixed on whether scribes improve patient satisfaction. We studied whether scribes improved patient satisfaction in an academic otolaryngology clinic.

Methods:

The authors performed a retrospective review of patient responses to the Press Ganey survey between 12/2016 and 12/2017. Their responses about satisfaction with the provider and wait times were examined. Three providers worked with scribes during this year; each spent six months with a scribe and six without. The authors compared survey responses from periods with and without scribes using the Fischer exact test. Average overall provider ratings were compared using the Student’s t-test.

Results:

A total of 87 patients filled out Press Ganey surveys for the 3 providers over the year: 54 for visits without scribes, and 33 for visits with scribes. Fischer exact analysis demonstrated no significant difference in satisfaction with providers and wait times for both individual providers and all providers combined (all P > .05). There was also no difference in patients’ likelihood of recommending the provider’s office ( P = .91). Overall provider rating (0-10 scale) was high without scribes (9.48 ± 1.06) and was unchanged by the presence of scribes (9.53 ± 0.8) ( P = .97).

Conclusion:

Patient satisfaction with wait times and providers was high overall and was not affected by the presence of a medical scribe.

Utilizing a Physician Scribe in a Pediatric Plastic Surgical Practice: A Time-driven Activity-based Costing Study

To use time-driven activity-based costing methodology to compare the costs of routine pediatric plastic surgical patient visits with and without a physician scribe.

Delivering person-centered care with an electronic health record

BACKGROUND

Electronic health records are now widely adopted in medical and behavioral health settings. While they have the potential to improve the quality of care, the research findings on their impact on clinical practice and outcomes have been mixed. This study explores how the electronic health record and its stage of development influenced the implementation of person-centered care planning in community mental health clinics.

METHODS

The study was set in five community mental health clinics which utilized an EHR and had been trained in person-centered care planning. Using an objective quantitative measure of fidelity, the study examined fidelity to PCCP across time and by stage of EHR development. Data from focus groups, interviews with clinic leaders and consultant reports was analyzed to explore the process of implementation and the role of the electronic health record.

RESULTS

All clinics demonstrated an overall increase in PCCP fidelity at the conclusion of the study period but there were significant differences in PCCP fidelity among clinics with EHRs in different stages of development. Electronic health records emerged as a significant implementation factor in the qualitative data with clinics being unable to individualize service plans and encountering technical difficulties. Barriers to person-centered care included drop-down boxes and pre-determined outcomes. Clinic responses included customizing their record or developing workarounds.

CONCLUSIONS

The study demonstrated the need to align the electronic health record with a person-centered approach which includes individualizing information and orienting service plans to personal life goals. The ability of clinics to be able to customize their records and balance the need for unique and aggregate information in the record is critical to improve both the provider experience and the quality of care.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT02299492 , registered on November 24, 2014.

Measuring electronic communication networks in virtual care teams using electronic health records access-log data

OBJECTIVE

To develop methods for measuring electronic communication networks in virtual care teams using electronic health records (EHR) access-log data.

METHODS

For a convenient sample of 100 surgical colorectal cancer patients, we used time-stamped EHR access-log data extracted from an academic medical center's EHR system to construct communication networks among healthcare professionals (HCPs) in each patient's virtual care team. We measured communication linkages between HCPs using the inverse of the average time between access events in which the source HCPs sent information to and the destination HCPs retrieved information from the EHR system. Social network analysis was used to examine and visualize communication network structures, identify principal care teams, and detect meaningful structural differences across networks. We conducted a non-parametric multivariate analysis of variance (MANOVA) to test the association between care teams' communication network structures and patients' cancer stage and site.

RESULTS

The 100 communication networks showed substantial variations in size and structures. Principal care teams, the subset of HCPs who formed the core of the communication networks, had higher proportions of nurses, physicians, and pharmacists and a lower proportion of laboratory medical technologists than the overall networks. The distributions of conditional uniform graph quantiles suggested that our network-construction technique captured meaningful underlying structures that were different from random unstructured networks. MANOVA results found that the networks' topologies were associated with patients' cancer stage and site.

CONCLUSIONS

This study demonstrates that it is feasible to use EHR access-log data to measure and examine communication networks in virtual care teams. The proposed methods captured salient communication patterns in care teams that were associated with patients' clinical differences.

Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings

Pediatric populations are uniquely vulnerable to the usability and safety challenges of electronic health records (EHRs), particularly those related to medication, yet little is known about the specific issues contributing to hazards. To understand specific usability issues and medication errors in the care of children, we analyzed 9,000 patient safety reports, made in the period 2012-17, from three different health care institutions that were likely related to EHR use. Of the 9,000 reports, 3,243 (36 percent) had a usability issue that contributed to the medication event, and 609 (18.8 percent) of the 3,243 might have resulted in patient harm. The general pattern of usability challenges and medication errors were the same across the three sites. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing.

A Daily Hospital Progress Note that Increases Physician Usability of the Electronic Health Record by Facilitating a Problem-Oriented Approach to the Patient and Reducing Physician Clerical Burden

We suggest changes in the electronic health record (EHR) in hospitalized patients to increase EHR usability by optimizing the physician's ability to approach the patient in a problem-oriented fashion and by reducing physician data entry and chart navigation. The framework for these changes is a Physician's Daily Hospital Progress Note organized into 3 sections: Subjective, Objective, and a combined Assessment and Plan section, subdivided by problem titles. The EHR would consolidate information for each problem by: 1) juxtaposing to each problem title relevant medications, key durable results, and limitations; 2) entering in the running lists under Assessment and Plan the most relevant information for that day, including abbreviated versions of relevant reports; and 3) generating a flow sheet in a problem's progress note for any key results tracked daily. To reduce physician EHR navigation, the EHR would place in the Objective section abbreviated versions of notes of other physicians, nurses, and allied health professionals as well as recent orders. The physician would enter only the analysis and plan and new information not included in the EHR. The consolidation of information for each problem would facilitate physician communication at points of transition of care including generation of a problem-oriented discharge summary.

A systematic literature review of machine learning in online personal health data

OBJECTIVE

User-generated content (UGC) in online environments provides opportunities to learn an individual's health status outside of clinical settings. However, the nature of UGC brings challenges in both data collecting and processing. The purpose of this study is to systematically review the effectiveness of applying machine learning (ML) methodologies to UGC for personal health investigations.

MATERIALS AND METHODS

We searched PubMed, Web of Science, IEEE Library, ACM library, AAAI library, and the ACL anthology. We focused on research articles that were published in English and in peer-reviewed journals or conference proceedings between 2010 and 2018. Publications that applied ML to UGC with a focus on personal health were identified for further systematic review.

RESULTS

We identified 103 eligible studies which we summarized with respect to 5 research categories, 3 data collection strategies, 3 gold standard dataset creation methods, and 4 types of features applied in ML models. Popular off-the-shelf ML models were logistic regression (n = 22), support vector machines (n = 18), naive Bayes (n = 17), ensemble learning (n = 12), and deep learning (n = 11). The most investigated problems were mental health (n = 39) and cancer (n = 15). Common health-related aspects extracted from UGC were treatment experience, sentiments and emotions, coping strategies, and social support.

CONCLUSIONS

The systematic review indicated that ML can be effectively applied to UGC in facilitating the description and inference of personal health. Future research needs to focus on mitigating bias introduced when building study cohorts, creating features from free text, improving clinical creditability of UGC, and model interpretability.

Understanding of and Barriers to Electronic Health Record Patient Portal Access in a Culturally Diverse Pediatric Population

Background

Electronic health records (EHRs) have become a standard in the health care setting. In an effort to improve health literacy, foster doctor-patient communication, and ease the transition from adolescent to adult care, our institution created a policy that allows patients aged between 13 and 17 years to have EHR portal access. A literature review revealed predictable differences in portal registration among different ethnicities and socioeconomic statuses. Consequently, a cross-sectional survey was developed to investigate barriers to EHR portal access in a sample of culturally diverse adolescents.

Objective

The aim of this study was to assess for barriers to EHR portal access in a culturally diverse adolescent population.

Methods

A 42-item anonymous survey was completed by 97 adolescents aged between 13 and 18 years, attending general pediatrics clinics. The results were analyzed using descriptive statistics and t tests.

Results

The average participant age was 15.5 (SD 1.5) years with 60% (58/97) male and 40% (39/97) female. Participants were 44% (43/97) black, 41% (40/97) Hispanic, 9% (9/97) Caucasian, 3% (3/97) Asian, and 2% (2/97) others. There were statistically significant differences in perceptions of confidentiality in age (13 to 15 years vs 16 to 18 years; P=.001) and insurance status (government vs private; P=.012) but not in gender, ethnicity, or parental education level. Younger adolescents with governmental insurance were more confident in the level of confidentiality with their physician. A total of 94% of participants had heard of the term EHR, but only 55% were familiar with its function. Furthermore, 77% of patients primarily accessed the internet through phones, and 50% of participants knew that patients aged under 18 years could obtain care for mental health, substance abuse, sexual health, and pregnancy.

Conclusions

This research has identified gaps in EHR technology with regard to the pediatric patient population. The results of our survey show that adolescents may have misconceptions regarding the doctor-patient relationship, their ability to obtain care, and the modalities present in an EHR. As technology progresses, it is essential to have a deeper understanding of adolescents’ perceptions of confidentiality, technology, and available resources to design an EHR system that encourages patient education and communication while limiting barriers to care.

A Clinical Care Monitoring and Data Collection Tool (H3 Tracker) to Assess Uptake and Engagement in Mental Health Care Services in a Community-Based Pediatric Integrated Care Model: Longitudinal Cohort Study

BACKGROUND

National recommendations for pediatric integrated care models include improved capacity for care coordination and communication across primary care and specialty mental health providers using technology, yet few practical, short-term solutions are available for low-resource, community-based pediatric integrated care clinics.

OBJECTIVE

The goal of the paper is to describe the development and features of a Web-based tool designed for program evaluation and clinician monitoring of embedded pediatric mental health care using a community-partnered approach. In addition, a longitudinal study design was used to assess the implementation of the tool in program evaluation, including clinical monitoring and data collection.

METHODS

Biweekly meetings of the partnered evaluation team (clinic, academic, and funding partners) were convened over the course of 12 months to specify tool features using a participatory framework, followed by usability testing and further refinement during implementation.

RESULTS

A data collection tool was developed to collect clinic population characteristics as well as collect and display patient mental health outcomes and clinical care services from 277 eligible caregiver/child participants. Despite outreach, there was little uptake of the tool by either the behavioral health team or primary care provider.

CONCLUSIONS

Development of the H3 Tracker (Healthy Minds, Healthy Children, Healthy Chicago Tracker) in two community-based pediatric clinics with embedded mental health teams serving predominantly minority children is feasible and promising for on-site program evaluation data collection. Future research is needed to understand ways to improve clinic integration and examine whether promotion of primary care/mental health communication drives sustained use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02699814; https://clinicaltrials.gov/ct2/show/NCT02699814 (Archived by WebCite at http://www.webcitation.org/772pV5rWW).

Communication, learning and assessment: Exploring the dimensions of the digital learning environment

Advances in technology make it possible to supplement in-person teaching activities with digital learning, use electronic records in patient care, and communicate through social media. This relatively new "digital learning environment" has changed how medical trainees learn, participate in patient care, are assessed, and provide feedback. Communication has changed with the use of digital health records, the evolution of interdisciplinary and interprofessional communication, and the emergence of social media. Learning has evolved with the proliferation of online tools such as apps, blogs, podcasts, and wikis, and the formation of virtual communities. Assessment of learners has progressed due to the increasing amounts of data being collected and analyzed. Digital technologies have also enhanced learning in resource-poor environments by making resources and expertise more accessible. While digital technology offers benefits to learners, the teachers, and health care systems, there are concerns regarding the ownership, privacy, safety, and management of patient and learner data. We highlight selected themes in the domains of digital communication, digital learning resources, and digital assessment and close by providing practical recommendations for the integration of digital technology into education, with the aim of maximizing its benefits while reducing risks.

SEWA: A framework for sociotechnical analysis of electronic health record system workarounds

OBJECTIVE

To develop a conceptual framework, SEWA, to address challenges of studying workarounds emerging from Electronic Health Record (EHR) system usage.

MATERIALS AND METHODS

SEWA is based on direct observations and follow-up interviews with physicians, nurses and clerks using their EHR at a large academic hospital. SEWA was developed by an iterative process: each new version was reviewed by experts (case study participants, hospital management, EHR developers) and refined accordingly till deemed final.

RESULTS

SEWA defines the work system and its five components constituting the context in which EHR workarounds are created. It also contains 15 rationales for creating EHR workarounds. Furthermore, four attributes are included that define EHR workarounds: cascadedness, anticipatedness, avoidability, and repetitiveness. Finally, SEWA lists the possible effects of workarounds on outcomes of clinical processes in terms of scope and impact.

DISCUSSION

SEWA provides a grounded foundation for performing sociotechnical analyses of EHR workarounds based on components of the work system. SEWA can likewise be supportive in planning redesign efforts of the work system. Finally, workarounds are subject to gradual change caused by e.g. changes in one's knowledge of the EHR, hospital policies, care directives, and system updates. Snapshots of SEWA can be taken over time and compared to gain insights into the evolution of workarounds.

CONCLUSION

Given the absence of a sociotechnical framework to study EHR workarounds, SEWA could aid researchers and practitioners to identify, analyze and resolve workarounds, and thereby contribute to improved patient safety, effectiveness of care and efficiency of care.

Information processing in electronic medical records: A survey validation

OBJECTIVE

The purpose of this study was to validate the Clinical Information Processing Instrument. This instrument attempts to examine information processing in electronic medical records (EMRs). We drew upon the theory of swift and even flow to guide survey development and construction.

MATERIALS AND METHODS

We used a mixed-methods approach to gather data from registered nurses. Nurses were invited to participate in focus groups, an expert panel, and the survey validation process. A semi-structured questionnaire addressed the following themes: method of communication, quality of information, and usability of the system.

RESULTS

We conducted a confirmatory factor analysis using structural equation modelling. The Kaiser-Meyer-Olkin measure was greater than 0.7 (0.90), and the Bartlett's test of sphericity was significant (X²  = 1519.03, df = 105, P < 0.001). The proposed structural equation model was analysed and revised to a final model that was statistically significant. The final survey, Clinical Information Processing Instrument, contained 18 Likert scale questions that supported the tenets of the theory of swift and even flow.

DISCUSSION

The nurses perceived EMRs as efficient for medication management, time management, and communication. The Clinical Information Processing Instrument is a validated survey tool that assesses information flow in EMRs.

CONCLUSIONS

The Clinical Information Processing Instrument was validated as an approach to analyse the utility of EMR in disseminating information among clinical staff. To increase the utility and meaningful use of EMR systems, it is important to consider factors that affect the distribution of information among clinicians.

Using Electronic Health Records To Generate Phenotypes For Research

Electronic health records contain patient-level data collected during and for clinical care. Data within the electronic health record include diagnostic billing codes, procedure codes, vital signs, laboratory test results, clinical imaging, and physician notes. With repeated clinic visits, these data are longitudinal, providing important information on disease development, progression, and response to treatment or intervention strategies. The near universal adoption of electronic health records nationally has the potential to provide population-scale real-world clinical data accessible for biomedical research, including genetic association studies. For this research potential to be realized, high-quality research-grade variables must be extracted from these clinical data warehouses. We describe here common and emerging electronic phenotyping approaches applied to electronic health records, as well as current limitations of both the approaches and the biases associated with these clinically collected data that impact their use in research. © 2018 by John Wiley & Sons, Inc.

Inpatient electronic health record maintenance from 2010 to 2015

OBJECTIVES

To describe the scale and scope of inpatient electronic health record (EHR) maintenance following initial implementation.

STUDY DESIGN

A retrospective study reviewing EHR change documentation within an integrated healthcare delivery system that has 21 hospitals.

METHODS

Between 2010 and 2015, we identified and categorized all significant changes made to the inpatient EHR, as documented within monthly EHR communication updates. We categorized EHR changes as updates to existing functionality or upgrades to new functionality. We grouped changes within larger functional domains as orders, alerts and customization, surgical and emergency department (ED), data review, reports and health information management, and other. We also identified the clinical areas and user roles targeted by these changes.

RESULTS

Over a 6-year period, 5551 unique changes were made to the inpatient EHR, with a median of 72 changes per month. Changes most frequently targeted orders (44.7% of 2190 change documents) and order sets (29.9% of documents). In total, changes affected 135 EHR functions. A total of 151 unique user roles were affected by these changes, with the most frequent roles including nurses (30.6%), physicians (26.6%), and other clinical staff (22.7%). The clinical areas most targeted by changes included surgical areas and the ED.

CONCLUSIONS

Over 6 years, EHR maintenance for clinical functionality was substantial and varied with pervasive impacts, requiring persistent attention, diverse expertise, and interdisciplinary collaboration.

Toward the Design of an Engagement Tool for Effective Electronic Health Record Adoption

As healthcare systems continue to expand their use of electronic health records (EHRs), barriers to robust and successful engagement with such systems by stakeholders remain tenacious. To this effect, this research presents the results of a survey tool utilizing both original and modified constructs from the Consolidated Framework for Implementation Research to assess key points of engagement barriers and potential points of intervention for stakeholders of EHRs in a large-scale healthcare organization (500-bed level II regional trauma center). Based on the extensive assessment, the paper presents recommendations for the utility of engagement process modeling and discusses how intervention opportunities can be used to mitigate engagement barriers.

Clinical Documentation in Electronic Health Record Systems: Analysis of Patient Record Review During Outpatient Ophthalmology Visits

Busy clinicians struggle with productivity and usability in electronic health record systems (EHRs). While previous studies have investigated documentation practices and strategies in the inpatient setting, outpatient documentation and review practices by clinicians using EHRs are relatively unknown. In this study, we look at clinicians' patterns of note review in the EHR during outpatient follow-up office visits in ophthalmology. Key findings from this study are that the number and percentage of notes reviewed is very low, there is variation between providers, specialties, and users, and staff access more notes than physicians. These findings suggest that the vast majority of content in the EHR is not being used by clinicians; improved EHR designs would better present this data and support the information needs of outpatient clinicians.

Too much or too little? Investigating the usability of high and low data displays of the same electronic medical record

The high data density on electronic medical record screens is touted as a major usability issue. However, it may not be a problem if the data is relevant and well-organized. Our objective was to test this assumption using a comprehensive set of measures that assess the three pillars of usability: efficiency (both physical and cognitive), effectiveness, and satisfaction. Physicians were asked to go through a series of tasks using two versions of the same electronic medical record: one where all the display items were separated into tabs (the original display), and one where important display items were grouped logically in one tab (the redesigned display). Results supported the hypothesis that combining relevant data in organized fashion into a smaller location would improve usability. The findings highlight the role of good display organization to mitigate the effects of high data density, as well as the importance of assessing cognitive load as part of usability studies.

Association of Medical Scribes in Primary Care With Physician Workflow and Patient Experience

IMPORTANCE

Widespread adoption of electronic health records (EHRs) in medical care has resulted in increased physician documentation workload and decreased interaction with patients. Despite the increasing use of medical scribes for EHR documentation assistance, few methodologically rigorous studies have examined the use of medical scribes in primary care.

OBJECTIVE

To evaluate the association of use of medical scribes with primary care physician (PCP) workflow and patient experience.

DESIGN, SETTING, AND PARTICIPANTS

This 12-month crossover study with 2 sequences and 4 periods was conducted from July 1, 2016, to June 30, 2017, in 2 medical center facilities within an integrated health care system and included 18 of 24 eligible PCPs.

INTERVENTIONS

The PCPs were randomly assigned to start the first 3-month period with or without scribes and then alternated exposure status every 3 months for 1 year, thereby serving as their own controls. The PCPs completed a 6-question survey at the end of each study period. Patients of participating PCPs were surveyed after scribed clinic visits.

MAIN OUTCOMES AND MEASURES

PCP-reported perceptions of documentation burden and visit interactions, objective measures of time spent on EHR activity and required for closing encounters, and patient-reported perceptions of visit quality.

RESULTS

Of the 18 participating PCPs, 10 were women, 12 were internal medicine physicians, and 6 were family practice physicians. The PCPs graduated from medical school a mean (SD) of 13.7 (6.5) years before the study start date. Compared with nonscribed periods, scribed periods were associated with less self-reported after-hours EHR documentation (<1 hour daily during week: adjusted odds ratio [aOR], 18.0 [95% CI, 4.7-69.0]; <1 hour daily during weekend: aOR, 8.7; 95% CI, 2.7-28.7). Scribed periods were also associated with higher likelihood of PCP-reported spending more than 75% of the visit interacting with the patient (aOR, 295.0; 95% CI, 19.7 to >900) and less than 25% of the visit on a computer (aOR, 31.5; 95% CI, 7.3-136.4). Encounter documentation was more likely to be completed by the end of the next business day during scribed periods (aOR, 2.8; 95% CI, 1.2-7.1). A total of 450 of 735 patients (61.2%) reported that scribes had a positive bearing on their visits; only 2.4% reported a negative bearing.

CONCLUSIONS AND RELEVANCE

Medical scribes were associated with decreased physician EHR documentation burden, improved work efficiency, and improved visit interactions. Our results support the use of medical scribes as one strategy for improving physician workflow and visit quality in primary care.

Framework to Enhance Nurses' Use of EMR

The ability of nurses to adopt and successfully use EMR is expected to have a significant impact on achieving benefits such as reduction in healthcare costs and improvement in healthcare quality. A review of the current research literature reveals issues and concerns relating to the adoption and use of EMR by nurses in hospital environments. This article presents a literature review of such issues and concerns, and suggests a framework for enhancing the adoption and use of EMR by nurses and hospitals.

Secondary EMR data for quality improvement and research: A comparison of manual and electronic data collection from an integrated critical care electronic medical record system

PURPOSE

This study measured the quality of data extracted from a clinical information system widely used for critical care quality improvement and research.

MATERIALS AND METHODS

We abstracted data from 30 fields in a random sample of 207 patients admitted to nine adult, medical-surgical intensive care units. We assessed concordance between data collected: (1) manually from the bedside system (eCritical MetaVision) by trained auditors, and (2) electronically from the system data warehouse (eCritical TRACER). Agreement was assessed using Cohen's Kappa for categorical variables and intraclass correlation coefficient (ICC) for continuous variables.

RESULTS

Concordance between data sets was excellent. There was perfect agreement for 11/30 variables (35%). The median Kappa score for the 16 categorical variables was 0.99 (IQR 0.92-1.00). APACHE II had an ICC of 0.936 (0.898-0.960). The lowest concordance was observed for SOFA renal and respiratory components (ICC 0.804 and 0.846, respectively). Score translation errors by the manual auditor were the most common source of data discrepancies.

CONCLUSIONS

Manual validation processes of electronic data are complex in comparison to validation of traditional clinical documentation. This study represents a straightforward approach to validate the use of data repositories to support reliable and efficient use of high quality secondary use data.

Electronic Health Record Interactions through Voice: A Review

BACKGROUND

Usability problems in the electronic health record (EHR) lead to workflow inefficiencies when navigating charts and entering or retrieving data using standard keyboard and mouse interfaces. Voice input technology has been used to overcome some of the challenges associated with conventional interfaces and continues to evolve as a promising way to interact with the EHR.

OBJECTIVE

This article reviews the literature and evidence on voice input technology used to facilitate work in the EHR. It also reviews the benefits and challenges of implementation and use of voice technologies, and discusses emerging opportunities with voice assistant technology.

METHODS

We performed a systematic review of the literature to identify articles that discuss the use of voice technology to facilitate health care work. We searched MEDLINE and the Google search engine to identify relevant articles. We evaluated articles that discussed the strengths and limitations of voice technology to facilitate health care work. Consumer articles from leading technology publications addressing emerging use of voice assistants were reviewed to ascertain functionalities in existing consumer applications.

RESULTS

Using a MEDLINE search, we identified 683 articles that were reviewed for inclusion eligibility. The references of included articles were also reviewed. Sixty-one papers that discussed the use of voice tools in health care were included, of which 32 detailed the use of voice technologies in production environments. Articles were organized into three domains: Voice for (1) documentation, (2) commands, and (3) interactive response and navigation for patients. Of 31 articles that discussed usability attributes of consumer voice assistant technology, 12 were included in the review.

CONCLUSION

We highlight the successes and challenges of voice input technologies in health care and discuss opportunities to incorporate emerging voice assistant technologies used in the consumer domain.

Analysis of the effects of EHR implementation on timeliness of care in a dermatology clinic: a simulation study

Objective

Quantify the downstream impact on patient wait times and overall length of stay due to small increases in encounter times caused by the implementation of a new electronic health record (EHR) system.

Methods

A discrete-event simulation model was created to examine the effects of increasing the provider-patient encounter time by 1, 2, 5, or 10 min, due to an increase in in-room documentation as part of an EHR implementation. Simulation parameters were constructed from an analysis of 52 000 visits from a scheduling database and direct observation of 93 randomly selected patients to collect all the steps involved in an outpatient dermatology patient care visit.

Results

Analysis of the simulation results demonstrates that for a clinic session with an average booking appointment length of 15 min, the addition of 1, 2, 5, and 10 min for in-room physician documentation with an EHR system would result in a 5.2 (22%), 9.8 (41%), 31.8 (136%), and 87.2 (373%) minute increase in average patient wait time, and a 6.2 (12%), 11.7 (23%), 36.7 (73%), and 96.9 (193%) minute increase in length of stay, respectively. To offset the additional 1, 2, 5, or 10 min, patient volume would need to decrease by 10%, 20%, 40%, and >50%, respectively.

Conclusions

Small changes to processes, such as the addition of a few minutes of extra documentation time in the exam room, can cause significant delays in the timeliness of patient care. Simulation models can assist in quantifying the downstream effects and help analyze the impact of these operational changes.