Clinician preferences for verbal communication compared to EHR documentation in the ICU

Enhancing interprofessional teamwork between youth care professionals using an electronic health record; a mixed methods intervention study

We aimed to investigate whether using a shared electronic patient record (EPR-Youth) strengthened interprofessional teamwork among professionals in youth care and child healthcare. Using a mixed-methods design, we compared two partly overlapping samples of professionals, who completed questionnaires before the introduction of EPR-Youth (n = 117) and 24 months thereafter (n = 127). Five components of interprofessional teamwork (interdependence, newly created professional activities, flexibility, collective ownership of goals, and reflection on processes) were assessed for this study. Midway through the study period, focus groups were held with 12 professionals to examine how EPR-Youth contributed to interprofessional teamwork. Professionals reported significantly more flexibility after the introduction of EPR-Youth than before. Professionals scored slightly -but not significantly- more positively on the other components of teamwork. Focus group participants reported that using EPR-Youth strengthened their sense of interdependence and collective ownership of goals, and contributed to newly created professional activities. At baseline, levels of interprofessional teamwork differed between organizations. Focus group participants confirmed these differences and attributed them to differences in facilitation of interprofessional teamwork. Our findings suggest that using EPR-Youth can foster interprofessional teamwork. Organizational differences underline that implementing an EPR alone is inadequate: shared definitions of teamwork and organizational facilities are needed to strengthen interprofessional teamwork.

Automating Electronic Health Record Data Quality Assessment

Information systems such as Electronic Health Record (EHR) systems are susceptible to data quality (DQ) issues. Given the growing importance of EHR data, there is an increasing demand for strategies and tools to help ensure that available data are fit for use. However, developing reliable data quality assessment (DQA) tools necessary for guiding and evaluating improvement efforts has remained a fundamental challenge. This review examines the state of research on operationalising EHR DQA, mainly automated tooling, and highlights necessary considerations for future implementations. We reviewed 1841 articles from PubMed, Web of Science, and Scopus published between 2011 and 2021. 23 DQA programs deployed in real-world settings to assess EHR data quality (n = 14), and a few experimental prototypes (n = 9), were identified. Many of these programs investigate completeness (n = 15) and value conformance (n = 12) quality dimensions and are backed by knowledge items gathered from domain experts (n = 9), literature reviews and existing DQ measurements (n = 3). A few DQA programs also explore the feasibility of using data-driven techniques to assess EHR data quality automatically. Overall, the automation of EHR DQA is gaining traction, but current efforts are fragmented and not backed by relevant theory. Existing programs also vary in scope, type of data supported, and how measurements are sourced. There is a need to standardise programs for assessing EHR data quality, as current evidence suggests their quality may be unknown.

A scoping review of distributed cognition in acute care clinical decision-making

Objectives

In acute care settings, interactions between providers and tools drive clinical decision-making. Most studies of decision-making focus on individual cognition and fail to capture critical collaborations. Distributed Cognition (DCog) theory provides a framework for examining the dispersal of tasks among agents and artifacts, enhancing the investigation of decision-making and error.

Content

This scoping review maps the evidence collected in empiric studies applying DCog to clinical decision-making in acute care settings and identifies gaps in the existing literature.

Summary and Outlook

Thirty-seven articles were included. The majority (n=30) used qualitative methods (observations, interviews, artifact analysis) to examine the work of physicians (n=28), nurses (n=27), residents (n=16), and advanced practice providers (n=12) in intensive care units (n=18), operating rooms (n=7), inpatient units (n=7) and emergency departments (n=5). Information flow (n=30) and task coordination (n=30) were the most frequently investigated elements of DCog. Provider-artifact (n=35) and provider-provider (n=30) interactions were most explored. Electronic (n=18) and paper (n=15) medical records were frequently described artifacts. Seven prominent themes were identified. DCog is an underutilized framework for examining how information is obtained, represented, and transmitted through complex clinical systems. DCog offers mechanisms for exploring how technologies, like EMRs, and workspaces can help or hinder clinical decision-making.

Readiness-Based Implementation of Electronic Health Records: A Survey of Jordanian Nurses

Electronic health record (EHR) implementation is expanding worldwide to achieve the benefits of that technology, but it is reported in the literature as a "disruptive" change to the work environment in which all health-care workers need to be ready for the change, to enhance adoption and harvest the benefits. Jordan has rolled out a national EHR system. This study explored EHR implementation readiness, levels of realizing the benefits of EHR, and adoption among Jordanian nurses, using a self-report questionnaire at nine governmental hospitals in Jordan. A total of 462 registered nurses participated in the study. Results showed that nurses have moderate levels of readiness for EHR implementation, but higher levels of EHR benefits realization and adoption. All health-care workers' readiness for EHR implementation must be assessed regularly before, during, and after EHR implementation. Readiness-based roll-out can be used as a strategy in implementing EHR systems. Introducing a large-scale change management program is recommended to assess readiness, guide roll-out plans, enhance EHR implementation readiness, improve benefits realization, and increase EHR adoption levels, to help move health-care systems into the digital era.

A Research Agenda for Diagnostic Excellence in Critical Care Medicine

Diagnosing critically ill patients in the intensive care unit is difficult. As a result, diagnostic errors in the intensive care unit are common and have been shown to cause harm. Research to improve diagnosis in critical care medicine has accelerated in past years. However, much work remains to fully elucidate the diagnostic process in critical care. To achieve diagnostic excellence, interdisciplinary research is needed, adopting a balanced strategy of continued biomedical discovery while addressing the complex care delivery systems underpinning the diagnosis of critical illness.

Pilot Testing of Simulation in the Evaluation of a Novel, Rapidly Deployable Electronic Health Record for use in Disaster Intensive Care

OBJECTIVES

The SARS-CoV-2 pandemic has highlighted the need for rapid creation and management of ICU field hospitals with effective remote monitoring which is dependent on the rapid deployment and integration of an Electronic Health Record (EHR). We describe the use of simulation to evaluate a rapidly scalable hub-and-spoke model for EHR deployment and monitoring using asynchronous training.

METHODS

We adapted existing commercial EHR products to serve as the point of entry from a simulated hospital and a separate system for tele-ICU support and monitoring of the interfaced data. To train our users we created a modular video-based curriculum to facilitate asynchronous training. Effectiveness of the curriculum was assessed through completion of common ICU documentation tasks in a high-fidelity simulation. Additional endpoints include assessment of EHR navigation, user satisfaction (Net Promoter), system usability (System Usability Scale-SUS), and cognitive load (NASA-TLX).

RESULTS

A total of 5 participants achieved a 100% task completion on all domains except ventilator data (91%). Systems demonstrated high degrees of satisfaction (Net Promoter = 65.2), acceptable usability (SUS = 66.5), and acceptable cognitive load (NASA-TLX = 41.5); with higher levels of cognitive load correlating with the number of screens employed.

CONCLUSIONS

Clinical usability of a comprehensive and rapidly deployable EHR was acceptable in an intensive care simulation which was preceded by < 1 hour of video education about the EHR. This model should be considered in plans for integrated clinical response with remote and accessory facilities.

Standardisation, multi-measure, data quality and trending: A qualitative study on multidisciplinary perspectives to improve intensive care early mobility monitoring

OBJECTIVE

To explore multi-clinician perspectives on intensive care early mobility, monitoring and to assess the perceived value of technology-generated mobility metrics to provide user feedback to inform research, practice improvement, and technology development.

METHODS

We performed a qualitative descriptive study. Three focus groups were conducted with critical care clinicians, including nurses (n = 10), physical therapists (n = 8) and physicians (n = 8) at an academic medical centre that implemented an intensive care early mobility programme in 2012. Qualitative thematic analysis was used to code transcripts and identify overarching themes.

FINDINGS

Along with reaffirming the value of performing early mobility interventions, four themes for improving mobility monitoring emerged, including the need for: 1) standardised indicators for documenting mobility; 2) inclusion of both quantitative and qualitative metrics to measure mobility 3) a balance between quantity and quality of data; and 4) trending mobility metrics over time.

CONCLUSION

Intensive care mobility monitoring should be standardised and data generated should be high quality, capable of supporting trend analysis, and meaningful. By improving measurement and monitoring of mobility, future researchers can examine the arc of activity that patients in the intensive care unit undergo and develop models to understand factors that influence successful implementation.

Information Needs and the Use of Documentation to Support Collaborative Decision-Making: Implications for the Reduction of Central Line-Associated Blood Stream Infections

It is clear that interdisciplinary communication and collaboration have the potential to mitigate healthcare-associated harm, yet there is limited research on how communication through documentation in the patient record can support collaborative decision making. Understanding what information is needed to support collaborative decision making is necessary to design electronic health information systems that facilitate effective communication and, ultimately, safe care. To explore this issue, we focused on information needs related to central venous catheter management and the prevention of central line-associated blood stream infections. Semistructured interviews were conducted with nurses working in an intensive care unit. Interview transcripts were analyzed using inductive thematic analysis. Three themes were identified: (1) challenges managing documentation in multiple places in the absence of formal documentation processes for central venous catheter management; (2) lack of standardized decision-making processes for managing central venous catheters; and (3) oral communication holds it together. Our findings provide a foundation for the development of EHR functional requirements that enhance communication regarding the management of central venous catheters and facilitate the prompt removal of unnecessary lines.

The influence of electronic health record use on collaboration among medical specialties

Background

One of the main objectives of Electronic Health Records (EHRs) is to enhance collaboration among healthcare professionals. However, our knowledge of how EHRs actually affect collaborative practices is limited. This study examines how an EHR facilitates and constrains collaboration in five outpatient clinics.

Methods

We conducted an embedded case study at five outpatient clinics of a Dutch hospital that had implemented an organization-wide EHR. Data were collected through interviews with representatives of medical specialties, administration, nursing, and management. Documents were analyzed to contextualize these data. We examined the following collaborative affordances of EHRs: (1) portability, (2) co-located access, (3) shared overviews, (4) mutual awareness, (5) messaging, and (6) orchestrating.

Results

Our findings demonstrate how an EHR will both facilitate and constrain collaboration among specialties and disciplines. Affordances that were inscribed in the system for collaboration purposes were not fully actualized in the hospital because:

(a) The EHR helps health professionals coordinate patient care on an informed basis at any time and in any place but only allows asynchronous patient record use.

(b) The comprehensive patient file affords joint clinical decision-making based on shared data, but specialty- and discipline-specific user-interfaces constrain mutual understanding of that data. Moreover, not all relevant information can be easily shared across specialties and outside the hospital.

(c) The reduced necessity for face-to-face communication saves time but is experienced as hindering collective responsibility for a smooth workflow.

(d) The EHR affords registration at the source and registration of activities through orders, but the heightened administrative burden for physicians and the strict authorization rules on inputting data constrain the flexible, multidisciplinary collaboration.

(e) While the EHR affords a complete overview, information overload occurs due to the parallel generation of individually owned notes and the high frequency of asynchronous communication through messages of varying clinical priority.

Conclusions

For the optimal actualization of EHRs’ collaborative affordances in hospitals, coordinated use of these affordances by health professionals is a prerequisite. Such coordinated use requires organizational, technical, and behavioral adaptations. Suggestions for hospital-wide policies to enhance trust in both the EHR and in its coordinated use for effective collaboration are offered.

Implementation of an Electronic Nursing Record for Nursing Documentation and Communication of Patient Care Information in a Tertiary Teaching Hospital

Despite the fact that implementing an electronic nursing record has become an everyday event for nurses, little is known about which type of documentation used in an electronic nursing record is better for nursing practice. The aim of this exploratory study was to identify the most suitable type of electronic nursing documentation that nurses used to record care and communicate with clinicians. Participants consisted of 118 nurses and 12 physicians. Researchers developed a self-report questionnaire of 17 items about electronic nursing record use for documentation and communication of patient care information. Data were analyzed using descriptive statistics to calculate frequencies and percentages. The χ2 test was used to identify differences in responses by demographic and clinical characteristics of participants. Bar charts were used to identify response patterns. Results showed that semistructured nursing documentation was the most preferred for care documentation and communication of patient information. Nurses did not always use the electronic nursing record to communicate patient care-related information. This study adds empirical knowledge about which type of documentation used in the electronic nursing record works well, what improvement is needed for better nursing practice, and whether the electronic nursing record has been used for communication.

Identifying best practices in electronic health record documentation to support interprofessional communication for the prevention of central line-associated bloodstream infections

BACKGROUND

There is a paucity of research on best practices for communication through the electronic health record (EHR) to support shared decision-making and to prevent adverse events. To explore this issue, this study focused on interprofessional communication around a specific clinical issue, the prevention of central line-associated bloodstream infections.

METHODS

The Delphi technique was used to describe what information is needed to support decisions regarding central venous catheter (CVC) management, and best practices for communicating this information among the interprofessional team.

RESULTS

The expert panel, 4 physicians and 6 nurses, identified 12 information types necessary for decisions regarding CVC management and the removal of unnecessary lines. For each of the 12 information types, the panel reached agreement regarding the best channel to communicate this information, including asynchronous EHR formats and synchronous oral channels.

CONCLUSIONS

Findings address 2 important aspects of postinsertion CVC practices and a gap in the literature by moving beyond a description of current practices to a description of how the EHR ought to be used to support collaboration and interprofessional communication. Future research should examine how the communication practices identified in this study contribute to a reduction in central line-associated bloodstream infections.

An Analysis of the Daily Work-Rounding Process in a Pediatric Intensive Care Unit

OBJECTIVE

To complete an objective analysis of the activities that occur during the course of daily rounds in a high acuity academic tertiary care pediatric intensive care unit (PICU).

DESIGN

Prospective observational work sampling design.

SETTING

Tertiary care academic Children's Hospital Pediatric Intensive Care Unit.

SUBJECTS

Multidisciplinary PICU teams.

INTERVENTIONS

None.

METHODS

Intensive care unit rounds were observed as part of an initiative to improve efficiency over a 2-month period. The number of observations required was determined by Neibel's work sampling method. Rounds were broken into various constituent events and then later classified as "value-added/essential," "value-added/nonessential," and "nonessential" based on whether the observed event was essential to the core mission of PICU rounds.

RESULTS

The mean time spent per patient for all observed teams was 17.9 min (SD 1.3 min). Teams spent 64% of their time doing value-added/essential tasks (11.2 min, SD 2.2 min) and 13% of their time doing value-added/nonessential tasks (2.4 min, SD 0.9 min). Teams spent 23% of their time on non-value-added activities (4.1 min, SD 2.3 min). The top three non-value-added activities conducted during rounds were travel, waiting, and interruptions regarding care of other patients. Given the consistency of time spent on value-added activities among attendings, these non-value-added activities might explain the significant variability observed among attendings in total time spent rounding.

CONCLUSIONS

This was an observational study to characterize the activities that occur during the course of a routine PICU work rounds. Although there was significant consistency in the time spent per patient in value-added activities, there was significant disparity in time spent on nonessential activities, such as travel and waiting. A dedicated attempt to reduce time spent on nonessential activities can substantially reduce rounding times and improve the efficiency and value of rounds.

Research Strategies for Biomedical and Health Informatics. Some Thought-provoking and Critical Proposals to Encourage Scientific Debate on the Nature of Good Research in Medical Informatics

BACKGROUND

Medical informatics, or biomedical and health informatics (BMHI), has become an established scientific discipline. In all such disciplines there is a certain inertia to persist in focusing on well-established research areas and to hold on to well-known research methodologies rather than adopting new ones, which may be more appropriate.

OBJECTIVES

To search for answers to the following questions: What are research fields in informatics, which are not being currently adequately addressed, and which methodological approaches might be insufficiently used? Do we know about reasons? What could be consequences of change for research and for education?

METHODS

Outstanding informatics scientists were invited to three panel sessions on this topic in leading international conferences (MIE 2015, Medinfo 2015, HEC 2016) in order to get their answers to these questions.

RESULTS

A variety of themes emerged in the set of answers provided by the panellists. Some panellists took the theoretical foundations of the field for granted, while several questioned whether the field was actually grounded in a strong theoretical foundation. Panellists proposed a range of suggestions for new or improved approaches, methodologies, and techniques to enhance the BMHI research agenda.

CONCLUSIONS

The field of BMHI is on the one hand maturing as an academic community and intellectual endeavour. On the other hand vendor-supplied solutions may be too readily and uncritically accepted in health care practice. There is a high chance that BMHI will continue to flourish as an important discipline; its innovative interventions might then reach the original objectives of advancing science and improving health care outcomes.

Understanding latent structures of clinical information logistics: A bottom-up approach for model building and validating the workflow composite score

BACKGROUND AND PURPOSE

Clinical information logistics is a construct that aims to describe and explain various phenomena of information provision to drive clinical processes. It can be measured by the workflow composite score, an aggregated indicator of the degree of IT support in clinical processes. This study primarily aimed to investigate the yet unknown empirical patterns constituting this construct. The second goal was to derive a data-driven weighting scheme for the constituents of the workflow composite score and to contrast this scheme with a literature based, top-down procedure. This approach should finally test the validity and robustness of the workflow composite score.

METHODS

Based on secondary data from 183 German hospitals, a tiered factor analytic approach (confirmatory and subsequent exploratory factor analysis) was pursued. A weighting scheme, which was based on factor loadings obtained in the analyses, was put into practice.

RESULTS

We were able to identify five statistically significant factors of clinical information logistics that accounted for 63% of the overall variance. These factors were "flow of data and information", "mobility", "clinical decision support and patient safety", "electronic patient record" and "integration and distribution". The system of weights derived from the factor loadings resulted in values for the workflow composite score that differed only slightly from the score values that had been previously published based on a top-down approach.

CONCLUSION

Our findings give insight into the internal composition of clinical information logistics both in terms of factors and weights. They also allowed us to propose a coherent model of clinical information logistics from a technical perspective that joins empirical findings with theoretical knowledge. Despite the new scheme of weights applied to the calculation of the workflow composite score, the score behaved robustly, which is yet another hint of its validity and therefore its usefulness.

Meta-generalis: A novel method for structuring information from radiology reports

BACKGROUND

A structured report for imaging exams aims at increasing the precision in information retrieval and communication between physicians. However, it is more concise than free text and may limit specialists' descriptions of important findings not covered by pre-defined structures. A computational ontological structure derived from free texts designed by specialists may be a solution for this problem. Therefore, the goal of our study was to develop a methodology for structuring information in radiology reports covering specifications required for the Brazilian Portuguese language, including the terminology to be used.

METHODS

We gathered 1,701 radiological reports of magnetic resonance imaging (MRI) studies of the lumbosacral spine from three different institutions. Techniques of text mining and ontological conceptualization of lexical units extracted were used to structure information. Ten radiologists, specialists in lumbosacral MRI, evaluated the textual superstructure and terminology extracted using an electronic questionnaire.

RESULTS

The established methodology consists of six steps: 1) collection of radiology reports of a specific MRI examination; 2) textual decomposition; 3) normalization of lexical units; 4) identification of textual superstructures; 5) conceptualization of candidate-terms; and 6) evaluation of superstructures and extracted terminology by experts using an electronic questionnaire. Three different textual superstructures were identified, with terminological variations in the names of their textual categories. The number of candidate-terms conceptualized was 4,183, yielding 727 concepts. There were a total of 13,963 relationships between candidate-terms and concepts and 789 relationships among concepts.

CONCLUSIONS

The proposed methodology allowed structuring information in a more intuitive and practical way. Indications of three textual superstructures, extraction of lexicon units and the normalization and ontologically conceptualization were achieved while maintaining references to their respective categories and free text radiology reports.

Professional and interprofessional differences in electronic health records use and recognition of safety issues in critically ill patients

During interprofessional intensive care unit (ICU) rounds each member of the interprofessional team is responsible for gathering and interpreting information from the electronic health records (EHR) to facilitate effective team decision-making. This study was conducted to determine how each professional group reviews EHR data in preparation for rounds and their ability to identify patient safety issues. Twenty-five physicians, 29 nurses, and 20 pharmacists participated. Individual participants were given verbal and written sign-out and then asked to review a simulated record in our institution's EHR, which contained 14 patient safety items. After reviewing the chart, subjects presented the patient and the number of safety items recognised was recorded. About 40%, 30%, and 26% of safety issues were recognised by physicians, nurses, and pharmacists, respectively (p = 0.0006) and no item recognised 100% of the time. There was little overlap between the three groups with only 50% of items predicted to be recognised 100% of the time by the team. Differential recognition was associated with marked differences in EHR use, with only 3/152 EHR screens utilised by all three groups and the majority of screens used exclusively only by one group. There were significant and non-overlapping differences in individual profession recognition of patient safety issues in the EHR. Preferential identification of safety issues by certain professional groups may be attributed to differences in EHR use. Future studies will be needed to determine if shared decision-making during rounds can improve recognition of safety issues.

Characterization of a handoff documentation tool through usage log data

Handoffs are a critical component of coordinated patient care; however, poor handoffs have been associated with near misses and adverse events. To address this, national agencies have recommended standardizing handoffs, for example through the use of handoff documentation tools. Recent research suggests that handoff tools, typically designed for physicians, are often used by non-physician providers as information sources. In this study, we investigated patterns of edits of an electronic handoff tool in a large teaching hospital through examination of its usage log data. Qualitative interviews with clinicians were used to triangulate log data findings. The analysis showed that despite its primary focus on facilitating transitions of care, information in the handoff documentation tool was updated throughout the day. Interviews with residents confirmed that they purposefully updated information to make it available for other members of their patient care teams. This further reiterates the view of electronic handoff tools as facilitators of team communication and coordination. However, the study also showed considerable variability in the frequency of updates between different units and across different patients. Further research is required to understand what factors drive such diversity in the use of electronic handoff tool and whether this diversity can be used to make inferences about patients' conditions.

Transferring patient care: patterns of synchronous bidisciplinary communication between physicians and nurses during handoffs in a critical care unit

PURPOSE

The transfer of patient care from one health care worker to another involves communication in high-pressure contexts that are often vulnerable to error. This research project captured current practices for handoffs during the critical care stage of surgical recovery in a hospital setting. The objective was to characterize information flow during transfer and identify patterns of communication between nurses and physicians.

DESIGN AND METHODS

Observations were used to document communication exchanges. The data were analyzed qualitatively according to the types of information exchanged and verbal behavior types.

FINDINGS

Reporting and questions were the most common verbal behaviors, and retrospective medical information was the focus of information exchange. The communication was highly interactive when discussing patient status and future care plans. Nurses proactively asked questions to capture a large proportion of the information they needed.

CONCLUSIONS

Findings reflect positive and constructive patterns of communication during handoffs in the observed hospital unit.