Supporting novice clinicians cognitive strategies: System design perspective.

Electronic Health Records: Promises and Realities: A 3-Part Series Part I: The Digital Sea Change, Ready or Not

The anticipated advantages of electronic health records (EHRs)-improved efficiency and the ability to share information across the healthcare enterprise-have so far failed to materialize. There is growing recognition that interoperability holds the key to unlocking the greatest value of EHRs. Health information technology (HIT) systems including EHRs must be able to share data and be able to interpret the shared data. This requires a controlled vocabulary with explicit definitions (data elements) as well as protocols to communicate the context in which each data element is being used (syntactic structure). Cardiac implantable electronic devices (CIEDs) provide a clear example of the challenges faced by clinicians when data is not interoperable. The proprietary data formats created by each CIED manufacturer, as well as the multiple sources of data generated by CIEDs (hospital, office, remote monitoring, acute care setting), make it challenging to aggregate even a single patient's data into an EHR. The Heart Rhythm Society and CIED manufacturers have collaborated to develop and implement international standard-based specifications for interoperability that provide an end-to-end solution, enabling structured data to be communicated from CIED to a report generation system, EHR, research database, referring physician, registry, patient portal, and beyond. EHR and other health information technology vendors have been slow to implement these tools, in large part, because there have been no financial incentives for them to do so. It is incumbent upon us, as clinicians, to insist that the tools of interoperability be a prerequisite for the purchase of any and all health information technology systems.

BackgroundPediatric hematopoietic cell transplantation (HCT), commonly referred to as blood and marrow transplantation (BMT), is an intense treatment modality that requires the involvement of engaged caregivers during the patient’s (child’s) prolonged hospitalization. The ubiquity of electronic health records (EHRs) and a trend toward patient-centered care could allow a novel health information technology (IT) system to increase parental engagement. The paucity of research on acute care, hospital-based (inpatient) health IT applications for patients or caregivers provides an opportunity for testing the feasibility of such applications. The pediatric BMT population represents an ideal patient group to conduct an evaluation due to the lengthy inpatient stays and a heightened need for patient activation.ObjectiveThe primary objective of this study is to assess the feasibility of implementing the BMT Roadmap in caregivers as an intervention during their child’s inpatient hospitalization. The BMT Roadmap is an inpatient portal prototype optimized for tablet with a user-centered design. It integrates patient-specific laboratory and medication data from the EHR in real-time and provides support in terms of discharge goals, home care education, and other components. Feasibility will be proven if (1) the BMT Roadmap functions and can be managed by the study team without unexpected effort, (2) the system is accessed by users at a defined minimum threshold, and (3) the qualitative and quantitative research conducted provides quality data that address the perceived usefulness of the BMT Roadmap and could inform a study in a larger sample size.MethodsThis will be a single-arm, nonrandomized feasibility study. We aim to enroll 10 adult caregivers (age ≥ 18 years) of pediatric patients (aged 0-25 years) undergoing autologous (self-donor) or allogeneic (alternative donor) BMT. Assenting minors (aged 10-18) will also be invited to participate. Recruitment of study participants will take place in the outpatient pediatric BMT clinic. After signing an informed consent, the research study team will provide participants with the BMT Roadmap, available on an Apple iPad, which will used throughout the inpatient hospitalization. To measure the study outcomes, approximately 6-8 semistructured qualitative interviews will be conducted periodically from pre-BMT to 100 days post-BMT and an additional 15-20 semistructured interviews will be conducted among BMT health care providers to assess perceived usefulness and usability of the system, as well as any associated workflow impacts. Quantitative survey instruments will only be administered to adult participants (age ≥ 18 years).ResultsRecruitment will begin in September 2015, and preliminary findings are expected in 2016.ConclusionsThis protocol offers a framework for the design and analysis of a personalized health IT system that has the potential to increase patient and caregiver engagement in acute care, hospital-based contexts.

The focus on healthcare information technology (IT) has led to remarkable growth in healthcare IT staffing.The federal government is moving ahead with its plan to advance the use of electronic health records (EHRs) in the U.S. healthcare system. The Centers for Medicare & Medicaid Services (CMS) recently collected public comments related to its proposed rule for Stage 2 of the “meaningful use” program. Under the three-stage program, hospitals and other healthcare facilities that demonstrate a meaningful use of EHRs are eligible for Medicare and Medicaid incentive payments.1 Stage 2 builds on Stage 1, laying out the requirements for healthcare providers.The push for EHRs got a huge boost with the American Recovery and Reinvestment Act of 2009, which committed billions of dollars to support the adoption and use of EHRs, building on an earlier goal that every American should have an electronic medical record by 2014. Fundamentally, EHRs are digital documentation that includes data from a visit to the doctor's office or office, including the patient's histories, exam notes, tests ordered and their results, drugs prescribed, and any other results or updated information. Some systems also check for drug interactions, can access X-rays, and even deliver a reminder for the patient to get a flu shot.2In certain quarters, hopes are high about the benefits of EHRs. Some talk of millions of dollars and thousands of hospitalizations saved—seemingly based on extrapolated data. Generally, there is the anticipation, especially by the government, that the use of EHRs will improve the quality, safety, and efficiency of healthcare delivery, as well as reduce medical errors, healthcare costs, and paperwork.On the other side of the coin, there are several who warn that it's premature to start talking about the benefits of EHRs, saying the transition will not be easy or fast. Take, for example, the benefits expected from data sharing. Peter Gabriel, director of informatics with the Department of Radiation Oncology at the University of Pennsylvania's School of Medicine, said that it could be 10 or 15 years before data sharing in health IT is widespread, because it's “a lot harder to achieve than most people appreciate. Simply implementing computer systems won't dramatically improve quality overnight.”3Obviously, health IT growth must also be tempered with risk assessment every step of the way. The development of 80001-1, the standard that deals with the application of risk management for IT networks that incorporate medical devices, indicates that risk analysis is getting woven into many health IT growth game plans. This kind of due diligence will likely stretch original timelines as they relate to the use of EHRs.CMS seems to be sensing that it will take a lot longer than initially anticipated as well. Its recent announcement, a notice of proposed rulemaking (NPRM), attempts to strike a balance between sustaining forward momentum toward meaningful use goals and ensuring that providers with greater obstacles to EHR adoption have the time, support, and incentive to catch up.4A survey published late last year by the Centers for Disease Control indicated that there is a wide variation among states in EHR adoption rates, ranging from a low of 40 percent to as much as 84 percent. As those numbers grow, so will healthcare IT staffing needs. According to the Bureau of Labor Statistics, the projected job growth rate for information security analysts, web developers, and computer network architects is 22% between 2010 and 2020. That's well above the average growth rate of 14% for all occupations during that same period. In its projection, found in the latest edition of the Occupational Outlook Handbook, the bureau makes note of the changes in healthcare and of their impact on this significant job growth.5“As the healthcare industry expands its use of electronic medical records, ensuring patients' privacy and protecting personal data are becoming more important,” the handbook reads. “More information security analysts are likely to be needed to create the safeguards that will satisfy patients' concerns. Demand for computer network architects will increase as firms continue to expand their use of wireless and mobile networks. This occupation will be needed to design and build these new networks, as well as upgrade existing ones. In addition, the expansion of healthcare information technology will cause an increase in the use of networking technology in that industry, and more computer network architects will be employed there.”The bureau makes a similar point in its projection of a 28% growth rate for jobs for network and computer systems administrators, again emphasizing the role of healthcare in fueling the demand.“Growth is expected in healthcare industries as their use of information technology increases,” says the handbook. “More administrators will be required to manage the growing systems and networks found at hospitals and other healthcare institutions.”To help meet the expected demand for health IT workers, the Obama administration launched training programs for such workers. Funded under the auspices of the Office of the National Coordinator for Health Information Technology (ONC), this training is offered through 82 community colleges and nine universities across the country. As of January 2012, the administration says that community colleges have trained more than 9,000 students for health IT jobs, with nearly as many currently enrolled. For the participating universities, more than 1,200 have enrolled and almost 600 have already graduated as post-graduate and masters-level IT professionals. And there is an expected increase to about three times as many by the summer of 2013.There are other support mechanisms in place as well, such as the Health IT Workforce Curriculum from the ONC, which provides teaching materials at no cost to instructors. Yet another is the HIT Pro Exam, also from the ONC, with more than 2,000 examinees since its launch in May 2011. The exam shows perspective employers that the job candidate has the knowledge and skills required to work in health IT. If you've ever seriously considered moving to healthcare IT, there may not be a better opportunity.For some, the only incentive in participating in the meaningful use program may well be the immediate financial reward rather than the long-term gains. There are experts who say that the EHR program, as it currently stands, means more work and less efficiency. For example, the EHR collects data on a patient's smoking status which requires the provider to fill out another form to track smoking status for the meaningful use program. As Farzad Mostashari, MD, the national health IT coordinator said, “No wonder providers are saying that meaningful use is adding work and not making sense to them. We have a lot of learning to make meaningful use of meaningful use.”5To date, more the $3 billion has been paid out to some 2,000 hospitals and 41,000 physicians. In January 2012 alone, $519 million was paid to eligible providers with up to $44,000 each under the Medicare EHR Incentive Program and $64,000 each under the Medicaid program.3The transition to EHRs is expected to extend well into the next decade. The incentives for building a meaningful EHR system eventually turn into penalties for not complying under the federal program. Since Medicare and Medicaid reimbursements can mean more than 50% of a hospital's revenue, eligible providers have a significant financial interest in demonstrating meaningful use of EHRs.For healthcare technology management professionals, the time is ripe to learn new skills and take advantage of new job opportunities. We're already seeing health IT adopt more mainstream computing and networking initiatives and technologies such as virtualization and software defined networks. These kinds of technologies also generate risk analysis— another form of health IT growth requiring staffing. Once in place, newer technologies will relieve IT techs and engineers from some of the mundane network administrative duties. Automated network and software management protocols will also help keep track with and compliance to an ongoing and dynamic risk analysis.All of this adds up to a safer system, while improving the quality and efficiency of healthcare delivery. Healthcare IT organizations are going to need the staffing to keep pace with providing the newer technology to healthcare's advantage.

Cognitive requirements for primary care providers during the referral process: Information needed from and interactions with an electronic health record system

BackgroundThe US Department of Veterans Affairs (VA) has developed various health information technology (HIT) resources to provide accessible veteran-centered health care. Currently, the VA is undergoing a major reorganization of VA HIT to develop a fully integrated system to meet consumer needs. Although extensive system documentation exists for various VA HIT systems, a more centralized and integrated perspective with clear documentation is needed in order to support effective analysis, strategy, planning, and use. Such a tool would enable a novel view of what is currently available and support identifying and effectively capturing the consumer’s vision for the future.ObjectiveThe objective of this study was to develop the VA HIT Systems Matrix, a novel tool designed to describe the existing VA HIT system and identify consumers’ vision for the future of an integrated VA HIT system.MethodsThis study utilized an expert panel and veteran informant focus groups with self-administered surveys. The study employed participatory research methods to define the current system and understand how stakeholders and veterans envision the future of VA HIT and interface design (eg, look, feel, and function). Directed content analysis was used to analyze focus group data.ResultsThe HIT Systems Matrix was developed with input from 47 veterans, an informal caregiver, and an expert panel to provide a descriptive inventory of existing and emerging VA HIT in four worksheets: (1) access and function, (2) benefits and barriers, (3) system preferences, and (4) tasks. Within each worksheet is a two-axis inventory. The VA’s existing and emerging HIT platforms (eg, My HealtheVet, Mobile Health, VetLink Kiosks, Telehealth), My HealtheVet features (eg, Blue Button, secure messaging, appointment reminders, prescription refill, vet library, spotlight, vitals tracker), and non-VA platforms (eg, phone/mobile phone, texting, non-VA mobile apps, non-VA mobile electronic devices, non-VA websites) are organized by row. Columns are titled with thematic and functional domains (eg, access, function, benefits, barriers, authentication, delegation, user tasks). Cells for each sheet include descriptions and details that reflect factors relevant to domains and the topic of each worksheet.ConclusionsThis study provides documentation of the current VA HIT system and efforts for consumers’ vision of an integrated system redesign. The HIT Systems Matrix provides a consumer preference blueprint to inform the current VA HIT system and the vision for future development to integrate electronic resources within VA and beyond with non-VA resources. The data presented in the HIT Systems Matrix are relevant for VA administrators and developers as well as other large health care organizations seeking to document and organize their consumer-facing HIT resources.

IntroductionConsumer health IT applications have the potential to improve quality, safety and efficiency of consumers' interactions with the healthcare system. Yet little attention has been paid to human factors and...

ObjectivesCustomer discovery (CD) is a method to determine if there are actual customers for a product/service and what they would want before actually developing the product/service. This concept, however, is rather new to health information technology (IT) systems. Therefore, the aim of this paper was to demonstrate how to use the CD method in developing a comprehensive health IT service for patients with knee/leg pain.MethodsWe participated in a 6-week I-Corps program to perform CD, in which we interviewed 55 people in person, by phone, or by video conference within 6 weeks: 4 weeks in the United States and 2 weeks in Korea. The interviewees included orthopedic doctors, physical therapists, physical trainers, physicians, researchers, pharmacists, vendors, and patients. By analyzing the interview data, the aim was to revise our business model accordingly.ResultsUsing the CD approach enabled us to understand the customer segments and identify value propositions. We concluded that a facilitating tele-rehabilitation system is needed the most and that the most suitable customer segment is early stage arthritis patients. We identified a new design concept for the customer segment. Furthermore, CD is required to identify value propositions in detail.ConclusionsCD is crucial to determine a more desirable direction in developing health IT systems, and it can be a powerful tool to increase the potential for successful commercialization in the health IT field.

Electronic Health Records: Can Promise Be Fulfilled?

Health Information Technology: On The Fast Track At Last?

Background: Healthcare systems face significant challenges related to medical errors and adverse events. Health information technology (HIT) offers potential solutions by improving healthcare systems. This study investigated the impact of HIT on patient safety, addressing challenges associated with medical errors and adverse events. Methods: A comprehensive literature review was conducted using scientific databases up to September 2020. A total of 138 articles were retrieved, of which 38 aligned with the study’s objectives. HIT aspects analyzed included radio frequency identification (RFID), computerized physician order entry (CPOE), clinical decision support system (CDSS), health information system (HIS), information technology (IT), and electronic health record (EHR). The study examined HIT’s influence on patient safety factors such as medical-pharmaceutical errors, the care process, care volume and workflow, quality of care, side effects, and readmissions. A data collection form was designed for electronic data extraction, capturing key information. Extracted data were then analyzed and reported accordingly. Results: Regardless of HIT type, 29% of studies reported positive impacts, 31.6% somewhat positive, 36.8% required further investigation, and 2.6% with no positive effect on patient safety. Positive studies highlighted benefits such as reduced medication errors, improved diagnostics, accelerated services, error reduction, and enhanced patient safety. However, studies with negative findings cited drawbacks, including patient misidentification, inaccurate drug dosage calculations, partial information access, system dependence, and high implementation costs. Conclusion: Overall, HIT interventions are beneficial. However, given their broad scope, focused studies on individual technologies are necessary to facilitate more in-depth analysis and evaluation.

THE PROPER USE OF INFORMATION TECHNOLOGY IN health care remains widely debated. The notion that health information technology (HIT) can improve care is not new: since the 1960s, HIT has been examined as a tool to aid diagnosis and archive medical records. Half a century later, academics and policy makers continue to debate whether HIT tools such as electronic health records (EHRs) will save money or improve care. Advocates point to many studies demonstrating the benefits of EHRs. Critics argue that the best data come from a few leading institutions with locally developed systems, whereas data from commercial products in nonleading institutions are equivocal. This debate is anachronistic and misses the current issues facing the transition toward greater use of HIT. The urgency to focus on key issues in HIT adoption has increased since the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which provides nearly $30 billion in incentives for physicians and hospitals to adopt EHRs. The question is no longer whether information technology will be used in health care. It will be. The HITECH Act creates a mix of incentives and penalties that will induce a large proportion of physicians and hospitals to move toward EHR systems by the end of this decade. The discussion should now focus on whether HIT will support the models of care delivery that will help achieve broader policy goals: safer, more effective, and more efficient care. The inspiration for a better approach to HIT can best be described by the concept popularized by the Bauhaus school of architecture: “form ever follows function.” Applied to HIT, this suggests beginning with the “function” of integrated, efficient, team-oriented care and following with the “form,” or design of the IT. However, much of HIT today is designed to track billable episodes of care and focuses on maximizing revenue under fee-for-service payment systems. These EHR systems generally do not facilitate integrated, team-oriented, cost-conscious care. System Needs for HIT Applications That Can Drive Accountability

Implementation of large Health Information Technology (HIT) systems is critical to healthcare organizations and has seen heavy investment. However, research has not fully explored the adaptation of HIT systems, particularly the tensions between individual flexibility and organizational needs in the adaptation process. This study analyzes how Emergency Department (ED) clinicians adapted to a new hospital-wide Electronic Medical Records (EMR) system. We present four adaptation cases revealing two interrelated types of adaptations—technical and organizational—as responses to the new system in use. First, individual clinicians respond to the immediate alteration in workflows caused by the EMR, while the organizational adaptations later mitigate the changes in healthcare quality control resulting from the clinicians’ initial adaptation. Our analysis reflects the critical nature and value of both adaptation types, with an emphasis on the triggers and process of organizational adaptation, for the successful implementation of a socio-technical-political system in a healthcare organization.

IntroductionThe ability to utilize the electronic health record (EHR) without compromising the doctor-patient relationship (DPR) is an essential skill of all physicians and trainees, yet little time is spent on educating or assessing learners on needed techniques. To address this gap, we developed a conventional OSCE station coupled with a simulated patient chart within the Epic program in order to assess our students' skills utilizing the EHR during a patient encounter.MethodsOf third-year medical students, 119 were given full access to the patient's simulated chart 24 hours in advance of their OSCE to review clinical data. During an in-person OSCE with a standardized patient (SP), students performed a focused history and physical, using the EHR to verify allergies and medications. Students completed an electronic patient note graded by faculty. SPs evaluated the students on communication and interpersonal skills with specific rubric elements. Faculty graded the students' notes to evaluate their expression of clinical reasoning in the assessment and plan.ResultsTraining SPs and faculty to assess students on EHR skills was feasible. After implementation of a comprehensive curriculum focused on EHR and DPR, there was a significant difference on EHR-related communication skills (M = 76.4, SD = 17.6) versus (M = 37, SD = 28.9) before curriculum enhancement t (117.9) = −12.4, p <.001.DiscussionThe EHR OSCE station provided a standardized method of assessing students' EHR skills during a patient encounter. Challenges still exist in the technological requirements to develop and deliver cases in today's EHR platform.

Back to table of contents Previous article Next article Annual MeetingFull AccessHealth Technology Leader Describes What Lies AheadRobert Plovnick, M.D.Robert PlovnickSearch for more papers by this author, M.D.Published Online:20 Apr 2007https://doi.org/10.1176/pn.42.8.0028Robert Kolodner, M.D., will provide an update on fast-moving developments in the adoption health information technology and the issues such technology raises. Photo courtesy of Office of the National Coordinator for Health Information TechnologyElect ron ic h e a l t h r e c o r d s are around the corner. Learn about what is happening in this and other areas of healt h information technology and how it will impact you by attending a series of sessions at APA's 2007 annual meeting led by psychiatrist Robert Kolodner, M.D., APA's Corresponding Committee on Electronic Health Records, and APA's Department on Quality Improvement and Psychiatric Services.Kolodner is the interim national coordinator for health information technology in the Department of Health and Human Services. He will present the lecture “Moving National Health Information Technology Agenda Forward” on Tuesday, May 22, from noon to 1:30 p.m. in room 26 A/B, Upper Level, San Diego Convention Center.The Office of the National Coordinator oversees a variety of national projects including electronic health record (EHR) technical standards, software certification, security, and privacy (Psychiatric News, January 5). Kolodner has been involved in over-seeing, promoting, and guiding health information technology initiatives in the VA for many years. According to various government agencies and health care experts, health information technology, including EHRs, has great potential to improve health care quality, improve communication and care coordination, and prevent medical errors.Kolodner will discuss the activities and plans of the Office of the National Coordinator for Health Information Technology; provide a psychiatrist's perspective on the national vision and direction for health information technology; outline benefits of HIT for psychiatry, such as improved communication with other providers and automated medication interaction checking; and comment on some of the key concerns that psychiatrists and other physicians have about HIT, including privacy protection of electronic health information, cost and training burden to physicians, and disruption of clinical work flow.In addition, APA's Corresponding Committee on Electronic Health Records and Department on Quality Improvement and Psychiatric Services are sponsoring two health information technology activities at the annual meeting and will delve more deeply into some of the issues that Kolodner will cover. The first is a workshop on the fast-moving shift from paper to electronic health records,“ The National Health Information Network and Psychiatry: How Will EHRs Impact Our Patients and Our Practice?” It will be held on Tuesday, May 22, from 9 a.m. to 10:30 a.m. in Room 30 B, Upper Level, San Diego Convention Center.Second, to showcase the benefits of EHRs and to provide a means for meeting attendees to compare how different products shown in the Exhibit Hall handle the same information, the committee has developed a demonstration scenario that will be distributed to EHR vendors in advance of the meeting. This scenario, as well as a list of vendors, will be available on the committee's Web site at<www.psych.org/members/ehr>.▪Robert Plovnick, M.D., is APA's informatics and performance-measure specialist. ISSUES NewArchived