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Aubrey JM, Levine A, Movassaghi A, Liefeld HR, Hop A, Thompson J, Paul Wright G. 2021 CMS Evaluation and Management Guideline Changes Reduce Note Length in Outpatient Breast Surgery Documentation. Ann Surg Oncol 2024:10.1245/s10434-024-15800-0. [PMID: 39042231 DOI: 10.1245/s10434-024-15800-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 06/19/2024] [Indexed: 07/24/2024]
Affiliation(s)
- Jason M Aubrey
- General Surgery Residency, Corewell Health West/Michigan State University, Grand Rapids, MI, USA.
| | - Anna Levine
- General Surgery Residency, Corewell Health West/Michigan State University, Grand Rapids, MI, USA
| | - Aghdas Movassaghi
- College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| | - Hannah R Liefeld
- General Surgery Residency, Corewell Health West/Michigan State University, Grand Rapids, MI, USA
| | - Amie Hop
- Department of Surgical Oncology, Corewell Health West/Michigan State University, Grand Rapids, MI, USA
| | - Jessica Thompson
- Department of Surgical Oncology, Corewell Health West/Michigan State University, Grand Rapids, MI, USA
| | - G Paul Wright
- Department of Surgical Oncology, Corewell Health West/Michigan State University, Grand Rapids, MI, USA
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Shachak A, Buchanan F, Kuziemsky C. When rules turn into tools: An activity theory-based perspective on implementation processes and unintended consequences. Healthc Manage Forum 2024; 37:177-182. [PMID: 38377181 PMCID: PMC11044511 DOI: 10.1177/08404704241233169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
The idea that actions of people, organizations or governments may lead to Unintended Consequences (UICs) is not new. In health, UICs have been reported as a result of various interventions including quality improvement initiatives, health information technology implementation, and knowledge translation, especially those involving translation of broad policies (evidence-based medicine and patient-centred care) or system level improvement into actionable items or tools. While some unintended consequences cannot be anticipated, others may be predictable. In this article, we present a model based on cultural historical activity theory, which may help policy-makers, health leaders, and researchers better anticipate UICs resulting from implementation of new programs or technologies and take action to address them or mitigate their risk of occurrence. We support this model using examples of UICs of implementing family centred care principles, electronic health records, and computerized templates for quality improvement in chronic disease management.
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Affiliation(s)
- Aviv Shachak
- University of Toronto, Toronto, Ontario, Canada
- The Wilson Centre for Research in Education, Toronto, Ontario, Canada
| | - Francine Buchanan
- University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
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Braddock AS, Bosworth KT, Ghosh P, Proffitt R, Flowers L, Montgomery E, Wilson G, Tosh AK, Koopman RJ. Clinician Needs for Electronic Health Record Pediatric and Adolescent Weight Management Tools: A Mixed-Methods Study. Appl Clin Inform 2024; 15:368-377. [PMID: 38458233 PMCID: PMC11078569 DOI: 10.1055/a-2283-9036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/21/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Clinicians play an important role in addressing pediatric and adolescent obesity, but their effectiveness is restricted by time constraints, competing clinical demands, and the lack of effective electronic health record (EHR) tools. EHR tools are rarely developed with provider input. OBJECTIVES We conducted a mixed method study of clinicians who provide weight management care to children and adolescents to determine current barriers for effective care and explore the role of EHR weight management tools to overcome these barriers. METHODS In this mixed-methods study, we conducted three 1-hour long virtual focus groups at one medium-sized academic health center in Missouri and analyzed the focus group scripts using thematic analysis. We sequentially conducted a descriptive statistical analysis of a survey emailed to pediatric and family medicine primary care clinicians (n = 52) at two private and two academic health centers in Missouri. RESULTS Surveyed clinicians reported that they effectively provided health behavior lifestyle counseling at well-child visits (mean of 60 on a scale of 1-100) and child obesity visits (63); however, most felt the current health care system (27) and EHR tools (41) do not adequately support pediatric weight management. Major themes from the clinician focus groups were that EHR weight management tools should display data in a way that (1) improves clinical efficiency, (2) supports patient-centered communication, (3) improves patient continuity between visits, and (4) reduces documentation burdens. An additional theme was (5) clinicians trust patient data entered in real time over patient recalled data. CONCLUSION Study participants report that the health care system status quo and currently available EHR tools do not sufficiently support clinicians working to manage pediatric or adolescent obesity and provide health behavior counseling. Clinician input in the development and testing of EHR weight management tools provides opportunities to address barriers, inform content, and improve efficiencies of EHR use.
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Affiliation(s)
- Amy S. Braddock
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, United States
| | - K. Taylor Bosworth
- School of Medicine, University of Missouri, Columbia, Missouri, United States
| | - Parijat Ghosh
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, United States
| | - Rachel Proffitt
- School of Health Professions, University of Missouri, Columbia, Missouri, United States
| | - Lauren Flowers
- School of Medicine, University of Missouri, Columbia, Missouri, United States
| | - Emma Montgomery
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, United States
| | - Gwendolyn Wilson
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, United States
| | - Aneesh K. Tosh
- Department of Child Health, University of Missouri, Columbia, Missouri, United States
| | - Richelle J. Koopman
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, United States
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Executive summary of the meeting of the 2023 ASHP Commission on Goals: Optimizing Medication Therapy Through Advanced Analytics and Data-Driven Healthcare. Am J Health Syst Pharm 2024; 81:159-164. [PMID: 37971063 DOI: 10.1093/ajhp/zxad261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
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Stead WW, Miller RA, Ohno-Machado L, Bakken S. JAMIA at 30: looking back and forward. J Am Med Inform Assoc 2023; 31:1-9. [PMID: 38134400 PMCID: PMC10746314 DOI: 10.1093/jamia/ocad215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 10/30/2023] [Indexed: 12/24/2023] Open
Affiliation(s)
- William W Stead
- Department of Biomedical Informatics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Randolph A Miller
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Alexandria, VA 37232, United States
| | - Lucila Ohno-Machado
- Section of Biomedical Informatics & Data Science, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Suzanne Bakken
- School of Nursing, Department of Biomedical Informatics, Data Science Institute, Columbia University, New York, NY 10032, United States
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Khavandi S, Zaghloul F, Higham A, Lim E, de Pennington N, Celi LA. Investigating the Impact of Automation on the Health Care Workforce Through Autonomous Telemedicine in the Cataract Pathway: Protocol for a Multicenter Study. JMIR Res Protoc 2023; 12:e49374. [PMID: 38051569 PMCID: PMC10731565 DOI: 10.2196/49374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/17/2023] [Accepted: 09/18/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND While digital health innovations are increasingly being adopted by health care organizations, implementation is often carried out without considering the impacts on frontline staff who will be using the technology and who will be affected by its introduction. The enthusiasm surrounding the use of artificial intelligence (AI)-enabled digital solutions in health care is tempered by uncertainty around how it will change the working lives and practices of health care professionals. Digital enablement can be viewed as facilitating enhanced effectiveness and efficiency by improving services and automating cognitive labor, yet the implementation of such AI technology comes with challenges related to changes in work practices brought by automation. This research explores staff experiences before and after care pathway automation with an autonomous clinical conversational assistant, Dora (Ufonia Ltd), that is able to automate routine clinical conversations. OBJECTIVE The primary objective is to examine the impact of AI-enabled automation on clinicians, allied health professionals, and administrators who provide or facilitate health care to patients in high-volume, low-complexity care pathways. In the process of transforming care pathways through automation of routine tasks, staff will increasingly "work at the top of their license." The impact of this fundamental change on the professional identity, well-being, and work practices of the individual is poorly understood at present. METHODS We will adopt a multiple case study approach, combining qualitative and quantitative data collection methods, over 2 distinct phases, namely phase A (preimplementation) and phase B (postimplementation). RESULTS The analysis is expected to reveal the interrelationship between Dora and those affected by its introduction. This will reveal how tasks and responsibilities have changed or shifted, current tensions and contradictions, ways of working, and challenges, benefits, and opportunities as perceived by those on the frontlines of the health care system. The findings will enable a better understanding of the resistance or susceptibility of different stakeholders within the health care workforce and encourage managerial awareness of differing needs, demands, and uncertainties. CONCLUSIONS The implementation of AI in the health care sector, as well as the body of research on this topic, remain in their infancy. The project's key contribution will be to understand the impact of AI-enabled automation on the health care workforce and their work practices. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/49374.
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Affiliation(s)
- Sarah Khavandi
- Ufonia, Oxford, United Kingdom
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, United Kingdom
- Imperial College School of Medicine, Imperial College London, London, United Kingdom
| | - Fatema Zaghloul
- Operations and Management Science, Healthcare and Innovation, University of Bristol, Bristol, United Kingdom
| | - Aisling Higham
- Ufonia, Oxford, United Kingdom
- Royal Berkshire NHS Foundation Trust, Reading, United Kingdom
| | - Ernest Lim
- Ufonia, Oxford, United Kingdom
- Department of Computer Science, University of York, York, United Kingdom
| | | | - Leo Anthony Celi
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA, United States
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, United States
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Jedwab RM, Manias E, Redley B, Dobroff N, Hutchinson AM. Impacts of technology implementation on nurses' work motivation, engagement, satisfaction and well-being: A realist review. J Clin Nurs 2023; 32:6037-6060. [PMID: 37082879 DOI: 10.1111/jocn.16730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/27/2023] [Accepted: 04/05/2023] [Indexed: 04/22/2023]
Abstract
AIM To examine current literature for causal explanations on how, why and under what circumstances, implementation of a new hospital electronic medical record system or similar technology impacts nurses' work motivation, engagement, satisfaction or well-being. BACKGROUND Implementation of new technology, such as electronic medical record systems, affects nurses and their work, workflows and inter-personal interactions in healthcare settings. Multiple individual and organisational-level factors can affect technology adoption by nurses and may have negative consequences for nurses and patient safety. DESIGN Five-step realist review method and Realist And Meta-narrative Evidence Syntheses: Evolving Standards checklist was used to guide this review. Eight initial theories (programme theories) were used as the basis to explore, examine and refine literature from a range of sources. DATA SOURCES Literature from five databases (APA PsycInfo, CINAHL, Embase, IEEE Xplore and MEDLINE Complete) and grey literature (from 1 January 2000 to 31 October 2021) were systematically searched and retrieved on 4 November 2021. RESULTS In all, 8980 records were screened at the title and abstract level, of which 1027 full texts were screened and 10 were included in the review. Seven studies assessed concepts in both pre- and post-technology implementation. Most common contexts related to knowledge, rationale and skills to use new technology. Mechanisms that impacted nurses or nursing care delivery included: nurses' involvement in technology implementation processes; nurses' perceptions, understanding and limitations of technology impact(s) on patient care delivery; social supports; skills; implementation attitude and hardware. Work satisfaction was the most frequently examined outcome. An analysis led to nine final programme theories (including two original, six revised and one new programme theory). CONCLUSION Nurses must be informed about the rationale for new technology and have the knowledge and skills for its use. Understanding nurses' work motivation and attitudes related to technology adoption in the workplace can support work engagement, satisfaction and well-being. IMPLICATIONS FOR THE PROFESSION Complex contexts and mechanisms play a role in nurses' work motivation, engagement, satisfaction and well-being with the implementation of new technology into healthcare settings. RELEVANCE TO CLINICAL PRACTICE Nurses, their work and workflows are all influenced by the implementation of new technologies (such as electronic medical records), which in turn has consequences for patient safety and quality of care. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution. PROSPERO REGISTRATION NUMBER CRD42020131875 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131875).
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Affiliation(s)
- Rebecca M Jedwab
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University School of Nursing and Midwifery, Melbourne, Victoria, Australia
- Monash Health Nursing and Midwifery Informatics, Melbourne, Victoria, Australia
| | - Elizabeth Manias
- Institute for Health Transformation, Deakin University School of Nursing and Midwifery, Melbourne, Victoria, Australia
| | - Bernice Redley
- Deakin University School of Nursing and Midwifery, Melbourne, Victoria, Australia
| | - Naomi Dobroff
- Monash Health Nursing and Midwifery Informatics, Melbourne, Victoria, Australia
- Deakin University School of Nursing and Midwifery, Melbourne, Victoria, Australia
| | - Alison M Hutchinson
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University School of Nursing and Midwifery, Melbourne, Victoria, Australia
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Ballart X, Ferraioli F, Iruela A. [Administrative burden, motivation and well-being among primary care physicians: comparison of management models]. GACETA SANITARIA 2023; 37:102306. [PMID: 37263124 DOI: 10.1016/j.gaceta.2023.102306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 03/19/2023] [Accepted: 03/21/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To analyze the relationship between administrative burden and intrinsic motivation and between administrative burden and professional well-being among family and community medicine physicians. To analyze the extent to which attention to three basic needs (autonomy, sense of competence and relationship capacity) that one of the main motivation theories identifies as a generator of intrinsic motivation compensates for the negative effect of the administrative burden. To compare management models. METHOD Data from a survey (542 valid questionnaires) carried out through the Catalan Society of Family and Community Medicine are used. Data analysis is based on multiple regression and ANOVA techniques. RESULTS The perception of administrative burden and "red tape" are clearly demotivating and reduce job satisfaction. On the contrary, individual autonomy, networking opportunities between professionals and performance feedback are motivating and feed the perception of professional well-being. The EBA (Association Based Entity) model presents results above the ICS (Catalan Health Institute) and OSI (Integrated Health Organizations) models both in controlling the negative effect of administrative burden and in the management of basic psychological needs. CONCLUSIONS The motivation and professional well-being of primary care physicians would benefit from reforms that limit the administrative burden of some procedures and red tape. At the primary health center level, greater attention to individual autonomy, improving relatedness between professionals and the sense of competence based on better information on individual performance can offset the negative effects of the administrative burden.
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Affiliation(s)
- Xavier Ballart
- Departamento de Ciencia Política, Facultad de Ciencias Políticas y Sociología, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España.
| | - Francisco Ferraioli
- Departamento de Ciencia Política, Facultad de Ciencias Políticas y Sociología, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, España
| | - Antoni Iruela
- CAP Vallcarca, Barcelona, España; Departamento y Facultad de Medicina, Universitat de Vic, Barcelona, España
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Bakken S. Quantitative and qualitative methods advance the science of clinical workflow research. J Am Med Inform Assoc 2023; 30:795-796. [PMID: 37073766 PMCID: PMC10114099 DOI: 10.1093/jamia/ocad056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 04/20/2023] Open
Affiliation(s)
- Suzanne Bakken
- School of Nursing, Department of Biomedical Informatics and Data Science Institute, Columbia University, New York, New York, USA
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Abid M, Schneider AB. Clinical Informatics and the Electronic Medical Record. Surg Clin North Am 2023; 103:247-258. [PMID: 36948716 DOI: 10.1016/j.suc.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
The electronic medical record has fundamentally altered the way surgeons participate and practice medicine. There is now a wealth of data, once hidden behind paper records, that is, now available to surgeons to provide superior care to their patients. This article reviews the history of the electronic medical record, discusses use cases of additional data resources, and highlights the pitfalls of this relatively new technology.
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Affiliation(s)
- Mustafa Abid
- Department of Surgery, University of North Carolina, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | - Andrew B Schneider
- Department of Surgery, University of North Carolina, 101 Manning Drive, Chapel Hill, NC 27514, USA.
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Tolley C, Seymour H, Watson N, Nazar H, Heed J, Belshaw D. Barriers and Opportunities for the Use of Digital Tools in Medicines Optimization Across the Interfaces of Care: Stakeholder Interviews in the United Kingdom. JMIR Med Inform 2023; 11:e42458. [PMID: 36897631 PMCID: PMC10039399 DOI: 10.2196/42458] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 01/05/2023] [Accepted: 01/25/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND People with long-term conditions frequently transition between care settings that require information about a patient's medicines to be transferred or translated between systems. This process is currently error prone and associated with unintentional changes to medications and miscommunication, which can lead to serious patient consequences. One study estimated that approximately 250,000 serious medication errors occur in England when a patient transitions from hospital to home. Digital tools can equip health care professionals with the right information at the right time and place to support practice. OBJECTIVE This study aimed to answer the following questions: what systems are being used to transfer information across interfaces of care within a region of England? and what are the challenges and potential opportunities for more effective cross-sector working to support medicines optimization? METHODS A team of researchers at Newcastle University conducted a qualitative study by performing in-depth semistructured interviews with 23 key stakeholders in medicines optimization and IT between January and March 2022. The interviews lasted for approximately 1 hour. The interviews and field notes were transcribed and analyzed using the framework approach. The themes were discussed, refined, and applied systematically to the data set. Member checking was also performed. RESULTS This study revealed themes and subthemes pertaining to 3 key areas: transfer of care issues, challenges of digital tools, and future hopes and opportunities. We identified a major complexity in terms of the number of different medicine management systems used throughout the region. There were also important challenges owing to incomplete patient records. We also highlighted the barriers related to using multiple systems and their subsequent impact on user workflow, a lack of interoperability between systems, gaps in the availability of digital data, and poor IT and change management. Finally, participants described their hopes and opportunities for the future provision of medicines optimization services, and there was a clear need for a patient-centered consolidated integrated health record for use by all health and care professionals across different sectors, bridging those working in primary, secondary, and social care. CONCLUSIONS The effectiveness and utility of shared records depend on the data within; therefore, health care and digital leaders must support and strongly encourage the adoption of established and approved digital information standards. Specific priorities regarding understanding of the vision for pharmacy services and supporting this with appropriate funding arrangements and strategic planning of the workforce were also described. In addition, the following were identified as key enablers to harness the benefits of digital tools to support future medicines optimization: development of minimal system requirements; enhanced IT system management to reduce unnecessary repetition; and importantly, meaningful and continued collaboration with clinical and IT stakeholders to optimize systems and share good practices across care sectors.
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Affiliation(s)
- Clare Tolley
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
- Pharmacy Department, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Helen Seymour
- North East and North Cumbria Academic Health Science Network, Newcastle upon Tyne, United Kingdom
| | - Neil Watson
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
- Pharmacy Department, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Hamde Nazar
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jude Heed
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Dave Belshaw
- North East and North Cumbria Academic Health Science Network, Newcastle upon Tyne, United Kingdom
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Chien SC, Chen CY, Chien CH, Iqbal U, Yang HC, Hsueh HC, Weng SF, Jian WS. Investigating nurses' acceptance of patients' bring your own device implementation in a clinical setting: A pilot study. Asia Pac J Oncol Nurs 2023; 10:100195. [PMID: 36915387 PMCID: PMC10006526 DOI: 10.1016/j.apjon.2023.100195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/19/2023] [Indexed: 02/07/2023] Open
Abstract
Objective The popularity of the "bring your own device (BYOD)" concept has grown in recent years, and its application has extended to the healthcare field. This study was aimed at examining nurses' acceptance of a BYOD-supported system after a 9-month implementation period. Methods We used the technology acceptance model to develop and validate a structured questionnaire as a research tool. All nurses (n = 18) responsible for the BYOD-supported wards during the study period were included in our study. A 5-point Likert scale was used to assess the degree of disagreement and agreement. Statistical analysis was performed in SPSS version 24.0. Results The questionnaire was determined to be reliable and well constructed, on the basis of the item-level content validity index and Cronbach α values above 0.95 and 0.87, respectively. The mean constant values for all items were above 3.95, thus suggesting that nurses had a positive attitude toward the BYOD-supported system, driven by the characteristics of the tasks involved. Conclusions We successfully developed a BYOD-supported system. Our study results suggested that nursing staff satisfaction with BYOD-supported systems could be effectively increased by providing practical functionalities and reducing clinical burden. Hospitals could benefit from the insights generated by this study when implementing similar systems.
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Affiliation(s)
- Shuo-Chen Chien
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Artificial Intelligence Research and Development Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- International Center for Health Information and Technology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Chun-You Chen
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Artificial Intelligence Research and Development Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- International Center for Health Information and Technology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chia-Hui Chien
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- International Center for Health Information and Technology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Office of Public Affairs, Taipei Medical University, Taipei, Taiwan
| | - Usman Iqbal
- Health ICT, Department of Health, Tasmania, Australia
- Global Health and Health Security Department, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Hsuan-Chia Yang
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- International Center for Health Information and Technology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Huei-Chia Hsueh
- Department of Artificial Intelligence in Medicine, Professional Master Program, Taipei Medical University, Taipei, Taiwan
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuen-Fu Weng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wen-Shan Jian
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
- School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Research Center for Artificial Intelligence in Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Data Science, Taipei Medical University, Taipei, Taiwan
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Shaw J, Acharya C, Albhaisi S, Fagan A, McGeorge S, White MB, Lachar J, Olson J, Olofson A, Bergstrom L, Kamath PS, Bajaj JS. Subjective and objective burden on providers from a multicenter app-based study of patients with cirrhosis and caregivers. Hepatol Commun 2023; 7:e0030. [PMID: 36706194 PMCID: PMC9988316 DOI: 10.1097/hc9.0000000000000030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 10/30/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND App-based technologies could enhance patient and caregiver communication and provide alerts that potentially reducing readmissions. However, the burden of App alerts needs to be optimized to reduce provider burnout. AIM The purpose of this study was to determine subjective and objective burden of using the Patient Buddy App, a health information technology (HIT) on providers in a randomized multicenter trial, who completed a semi-quantitative Likert scale survey regarding training procedures, data and privacy concerns, follow-up details, and technical support. This randomized multicenter trial recruits cirrhosis inpatients and their caregivers, and randomizes them into standard-of-care, HIT (communication only via App) and HIT+visits (App+phone calls/visits) for 30 days after discharge. The alerts are monitored by providers through a central iPad. The reason(s) and number of alerts were recorded as the objective burden. A total of 1442 messages were sent as alerts from the 103 dyads (patient + caregiver) (n=206) randomized to HIT arms. The most common messages related to Hepatic Encephalopathy (HE) (high or low bowel movement=50% or orientation tests=37%). Twelve providers completed the surveys reflecting the following themes-92% and 100%, felt adequately trained and confident about educating the patients and caregivers before roll out of App and had no concerns related to data and privacy; 70%, felt that appropriate time was spent on pursuing reason for data not being logged; 60% each, had issues with availability of adequate technical support and connectivity. CONCLUSION The Patient Buddy App randomized multicenter trial till date shows an overall favorable rating regarding training procedures/education, privacy concerns, and ease of message follow-up, from providers. However, it is important to gauge and address subjective and objective burdens of monitoring human resources in current and future HIT studies to avoid burnout and to ensure successful study completion.
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Affiliation(s)
- Jawaid Shaw
- Division of Hospital Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Chathur Acharya
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Somaya Albhaisi
- Division of Hospital Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Andrew Fagan
- GI Section, Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Sara McGeorge
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Melanie B. White
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Jatinder Lachar
- Division of Hospital Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Jessica Olson
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Amy Olofson
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Lori Bergstrom
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
- GI Section, Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
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14
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Chen W, Howard K, Gorham G, O'Bryan CM, Coffey P, Balasubramanya B, Abeyaratne A, Cass A. Design, effectiveness, and economic outcomes of contemporary chronic disease clinical decision support systems: a systematic review and meta-analysis. J Am Med Inform Assoc 2022; 29:1757-1772. [PMID: 35818299 PMCID: PMC9471723 DOI: 10.1093/jamia/ocac110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 01/10/2023] Open
Abstract
Objectives Electronic health record-based clinical decision support (CDS) has the potential to improve health outcomes. This systematic review investigates the design, effectiveness, and economic outcomes of CDS targeting several common chronic diseases. Material and Methods We conducted a search in PubMed (Medline), EBSCOHOST (CINAHL, APA PsychInfo, EconLit), and Web of Science. We limited the search to studies from 2011 to 2021. Studies were included if the CDS was electronic health record-based and targeted one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolemia. Studies with effectiveness or economic outcomes were considered for inclusion, and a meta-analysis was conducted. Results The review included 76 studies with effectiveness outcomes and 9 with economic outcomes. Of the effectiveness studies, 63% described a positive outcome that favored the CDS intervention group. However, meta-analysis demonstrated that effect sizes were heterogenous and small, with limited clinical and statistical significance. Of the economic studies, most full economic evaluations (n = 5) used a modeled analysis approach. Cost-effectiveness of CDS varied widely between studies, with an estimated incremental cost-effectiveness ratio ranging between USD$2192 to USD$151 955 per QALY. Conclusion We summarize contemporary chronic disease CDS designs and evaluation results. The effectiveness and cost-effectiveness results for CDS interventions are highly heterogeneous, likely due to differences in implementation context and evaluation methodology. Improved quality of reporting, particularly from modeled economic evaluations, would assist decision makers to better interpret and utilize results from these primary research studies. Registration PROSPERO (CRD42020203716)
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Affiliation(s)
- Winnie Chen
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Gillian Gorham
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Claire Maree O'Bryan
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Patrick Coffey
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Bhavya Balasubramanya
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Asanga Abeyaratne
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
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15
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Nordtug M, Assing Hvidt E, Lüchau EC, Grønning A. General Practitioners' Experiences of Professional Uncertainties Emerging from the Introduction of Video Consultations in General Practice: A Qualitative Study. JMIR Form Res 2022; 6:e36289. [PMID: 35653607 PMCID: PMC9200054 DOI: 10.2196/36289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 01/20/2023] Open
Abstract
Background Uncertainties are omnipresent in health care, but little is known about general practitioners’ (GPs) professional uncertainties concerning digital consultations. This is problematic, as many countries have undergone an extensive digital transformation. Objective The aim of this study was to explore the professional uncertainties that emerged among Danish GPs with the introduction of video consultations. Methods We conducted qualitative interviews with 15 Danish GPs during the beginning of the COVID-19 pandemic in 2020. The interviews were analyzed using an abductive approach. Results We identified 3 categories of uncertainty: integrity, setting, and interaction. Respectively, these 3 categories of uncertainty refer to (1) uncertainties related to how technology may impede the provision of health care; (2) uncertainties related to the potentials of video technology; and (3) uncertainties related to how the video consultation technology affects interactions with patients. Conclusions The uncertainties experienced by Danish GPs appear to be a typical reaction to the introduction of new technology. Embedding video consultation technology into GPs’ working routines will take time, and GPs do not necessarily feel intuitively capable of transferring their abilities, such as being good and socially present for video-mediated consultations. The heterogeneity of professional uncertainties experienced among the GPs suggests that they are the product of individual GP-technology relationships—not of the technology in itself. Consequently, we cannot expect that uncertainties can be remedied by changing or precluding new technology.
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Affiliation(s)
- Maja Nordtug
- University of Southern Denmark, Campusvej 55, Odense M, DK.,Oslo Metropolitan University, Stensberggata 26, Oslo, NO
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16
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Robertson ST, Rosbergen IC, Burton-Jones A, Grimley RS, Brauer SG. The Effect of the Electronic Health Record on Interprofessional Practice: A Systematic Review. Appl Clin Inform 2022; 13:541-559. [PMID: 35649501 PMCID: PMC9179232 DOI: 10.1055/s-0042-1748855] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/28/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Interprofessional practice and teamwork are critical components to patient care in a complex hospital environment. The implementation of electronic health records (EHRs) in the hospital environment has brought major change to clinical practice for clinicians which could impact interprofessional practice. OBJECTIVES The aim of the study is to identify, describe, and evaluate studies on the effect of an EHR or modification/enhancement to an EHR on interprofessional practice in a hospital setting. METHODS Seven databases were searched including PubMed, Scopus, Web of Science, CINAHL, Cochrane, EMBASE, and ACM Digital Library until November 2021. Subject heading and title/abstract searches were undertaken for three search concepts: "interprofessional" and "electronic health records" and "hospital, personnel." No date limits were applied. The search generated 5,400 publications and after duplicates were removed, 3,255 remained for title/abstract screening. Seventeen studies met the inclusion criteria and were included in this review. Risk of bias was quantified using the Quality Assessment Tool for Studies with Diverse Designs. A narrative synthesis of the findings was completed based on type of intervention and outcome measures which included: communication, coordination, collaboration, and teamwork. RESULTS The majority of publications were observational studies and of low research quality. Most studies reported on outcomes of communication and coordination, with few studies investigating collaboration or teamwork. Studies investigating the EHR demonstrated mostly negative or no effects on interprofessional practice (23/31 outcomes; 74%) in comparison to studies investigating EHR enhancements which showed more positive results (20/28 outcomes; 71%). Common concepts identified throughout the studies demonstrated mixed results: sharing of information, visibility of information, closed-loop feedback, decision support, and workflow disruption. CONCLUSION There were mixed effects of the EHR and EHR enhancements on all outcomes of interprofessional practice, however, EHR enhancements demonstrated more positive effects than the EHR alone. Few EHR studies investigated the effect on teamwork and collaboration.
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Affiliation(s)
- Samantha T. Robertson
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
- Sunshine Coast Hospital and Health Service, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- Digital Health CRC, Sydney, New South Wales, Australia
| | - Ingrid C.M. Rosbergen
- Surgical Treatment and Rehabilitation Service (STARS), School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
- Surgical Treatment and Rehabilitation Service (STARS), Metro North Hospital and Health Service, Herston, Brisbane, Australia
| | | | - Rohan S. Grimley
- Sunshine Coast Hospital and Health Service, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- Sunshine Coast Clinical School, School of Medicine, University of Queensland, Brisbane, Australia
| | - Sandra G. Brauer
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
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17
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Stokar YN, Pat-Horenczyk R. Themes of end-of-life care in memorable cases of medical health professionals: A mixed methods approach. CURRENT PSYCHOLOGY 2022. [DOI: 10.1007/s12144-021-02566-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Haq C, Altman W, Wilson E, Iroku-Malize T, Blackwelder R, Robinson J. FROM ADFM: AMPLIFYING ADVOCACY IN FAMILY MEDICINE. Ann Fam Med 2021; 19:569-570. [PMID: 34750139 PMCID: PMC8575522 DOI: 10.1370/afm.2594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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19
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Almulhem JA, Aldekhyyel RN, Binkheder S, Temsah MH, Jamal A. Stress and Burnout Related to Electronic Health Record Use among Healthcare Providers during the COVID-19 Pandemic in Saudi Arabia: A Preliminary National Randomized Survey. Healthcare (Basel) 2021; 9:1367. [PMID: 34683047 PMCID: PMC8544434 DOI: 10.3390/healthcare9101367] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 02/03/2023] Open
Abstract
Healthcare providers' burnout may potentially have a negative impact on patient care. The use of the electronic health record (EHR) increases the burden for healthcare providers (HCPs), particularly during the coronavirus disease-2019 (COVID-19) pandemic. This study assessed the stress and burnout related to the use of EHRs and health information technology (HIT) tools among HCPs during COVID-19 in Saudi Arabia. We used a self-developed survey tool. It consisted of five sections; demographics and professional data, experience using EHR, effects of EHR use, use of EHR and technology tools during COVID-19, and health and wellbeing. The survey link was emailed to a random sample of HCPs registered with a national scientific regulatory body. Univariate, bivariate, and multivariate analyses were performed to measure the association between burnout and study variables. A total of 182 participants completed the survey. 50.5% of participants reported a presence of HIT-related stress, and 40.1% reported a presence of burnout. The variables independently associated with burnout were providing tertiary level of care, working with COVID-19 suspected cases, dissatisfaction with EHRs, and agreement with the statement that using EHRs added frustration to the workday. Further research that explores possible solutions is warranted to minimize burnout among HCPs, especially during infectious outbreaks.
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Affiliation(s)
- Jwaher A. Almulhem
- Medical Informatics and E-learning Unit, Medical Education Department, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia; (R.N.A.); (S.B.)
| | - Raniah N. Aldekhyyel
- Medical Informatics and E-learning Unit, Medical Education Department, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia; (R.N.A.); (S.B.)
| | - Samar Binkheder
- Medical Informatics and E-learning Unit, Medical Education Department, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia; (R.N.A.); (S.B.)
| | - Mohamad-Hani Temsah
- Pediatric Department, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia;
| | - Amr Jamal
- Evidence-Based Health Care & Knowledge Translation Research Chair, King Saud University, Riyadh 11362, Saudi Arabia;
- Family & Community Medicine Department, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
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20
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Hettinger AZ, Melnick ER, Ratwani RM. Advancing electronic health record vendor usability maturity: Progress and next steps. J Am Med Inform Assoc 2021; 28:1029-1031. [PMID: 33517394 DOI: 10.1093/jamia/ocaa329] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/18/2020] [Indexed: 11/13/2022] Open
Abstract
Despite basic federal requirements promoting a user-centered design approach to electronic health record (EHR) development and usability testing there have been usability and safety risks with EHR technology. Four EHR vendors were asked to provide written descriptions of their usability practices, and we reviewed these descriptions to identify areas where there has been advancement and areas for improvement. All 4 vendors described user-centered design processes and usability testing methods that demonstrate advancement from previous studies of vendor practices. Importantly, vendors are also beginning to address aspects of EHR implementation that play a critical role in shaping EHR usability. There are important areas for improvement in vendor practices including a greater focus on safety and on measurement and benchmarking. Vendors sharing their current usability practices demonstrates a step toward greater transparency which has typically been lacking.
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Affiliation(s)
- Aaron Z Hettinger
- MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, USA.,Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Raj M Ratwani
- MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, USA.,Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, USA
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21
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Carayon P, Salwei ME. Moving toward a sociotechnical systems approach to continuous health information technology design: the path forward for improving electronic health record usability and reducing clinician burnout. J Am Med Inform Assoc 2021; 28:1026-1028. [PMID: 33537756 DOI: 10.1093/jamia/ocab002] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/05/2021] [Indexed: 11/13/2022] Open
Abstract
Based on our analysis of descriptions provided by four EHR vendors on their EHR usability efforts, we provide three recommendations aimed at improving the usability of health information technology and reducing clinician burnout. First, EHR vendors need to dedicate increased attention to the design of the entire sociotechnical (work) system, including the EHR technology and its usability as well as the interactions of the technology with other system elements. Second, EHR vendors need to deepen and broaden their understanding of the work of clinicians and care teams by using diverse and mixed method. Third, in collaboration with health care organizations, EHR vendors should engage in cycles of continuous design and learning in order to improve the usability of health IT.
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Affiliation(s)
- Pascale Carayon
- Department of Industrial and Systems Engineering, Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Megan E Salwei
- Department of Biomedical Informatics, Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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22
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23
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Gettinger A, Zayas-Cabán T. HITECH to 21st century cures: clinician burden and evolving health IT policy. J Am Med Inform Assoc 2021; 28:1022-1025. [PMID: 33576379 PMCID: PMC8068412 DOI: 10.1093/jamia/ocaa330] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 12/17/2022] Open
Abstract
Adoption and use of health information technology (IT) was identified as 1 solution to quality and safety issues that permeate the United States health care system. Implementation of health IT has accelerated across the US over the past decade, in part, as a result of legislative and regulatory requirements and incentives. However, adoption of these systems has burdened clinician users due to design, configuration, and implementation issues, resulting in poor usability, challenges to workflow integration, and cumbersome documentation requirements. The path to alleviating these clinician burdens requires a clear understanding of the intent and evolution of pertinent regulations and the context in which they exist. This article reviews the Office of the National Coordinator of Health Information Technology's efforts, documents current regulatory actions, and discusses additional policy opportunities that can further improve clinician satisfaction and effectiveness in providing health care with health IT that is an asset, not an obstacle.
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Affiliation(s)
- Andrew Gettinger
- Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services, Washington, DC, USA
| | - Teresa Zayas-Cabán
- Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services, Washington, DC, USA
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