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Salahuddin L, Ismail Z, Abdul Rahim F, Anawar S, Hashim UR. Development and Validation of SafeHIT: An Instrument to Assess the Self-Reported Safe Use of Health Information Technology. Appl Clin Inform 2023; 14:693-704. [PMID: 37648223 PMCID: PMC10468731 DOI: 10.1055/s-0043-1771394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 06/05/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Implementing health information technology (HIT) may cause unintended consequences and safety risks when incorrectly designed and used. Yet, the tools to assess self-reported safe use of HIT are not well established. OBJECTIVE This study aims to develop and validate SafeHIT, an instrument to assess self-reported safe use of HIT among health care practitioners. METHODS Systematic literature review and a semistructured interview with 31 experts were adopted to generate SafeHIT instrument items. In total, 450 physicians from various departments at three Malaysian public hospitals participated in the questionnaire survey to validate SafeHIT. Exploratory factor analysis and confirmatory factor analysis (CFA) were undertaken to explore the items that best represent a specific construct and to confirm the reliability and validity of the SafeHIT, respectively. RESULTS The final SafeHIT consisted of 14 constructs and 58 items in total. The result of the CFA confirmed that all constructs demonstrated adequate convergent and discriminant validity. CONCLUSION A reliable and valid theoretically underpinned measure of determinants of safe HIT use behavior has been developed. Understanding external factors that influence safe HIT use is useful for developing targeted interventions that favor the quality and safety of health care.
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Affiliation(s)
- Lizawati Salahuddin
- Center for Advanced Computing Technology (C-ACT) Fakulti Teknologi Maklumat dan Komunikasi, Universiti Teknikal Malaysia Melaka (UTeM), Durian Tunggal, Melaka, Malaysia
| | | | - Fiza Abdul Rahim
- Advanced Informatics Department Razak Faculty of Technology and Informatics, Universiti Teknologi Malaysia (UTM), Kuala Lumpur, Malaysia
| | - Syarulnaziah Anawar
- Center for Advanced Computing Technology (C-ACT) Fakulti Teknologi Maklumat dan Komunikasi, Universiti Teknikal Malaysia Melaka (UTeM), Durian Tunggal, Melaka, Malaysia
| | - Ummi Rabaah Hashim
- Center for Advanced Computing Technology (C-ACT) Fakulti Teknologi Maklumat dan Komunikasi, Universiti Teknikal Malaysia Melaka (UTeM), Durian Tunggal, Melaka, Malaysia
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Kramer O, Even A, Matot I, Steinberg Y, Bitan Y. The impact of data quality defects on clinical decision-making in the intensive care unit. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 209:106359. [PMID: 34438224 DOI: 10.1016/j.cmpb.2021.106359] [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: 02/24/2021] [Accepted: 08/10/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Poor clinical data quality might affect clinical decision making and patient treatment. This study identifies quality defects in clinical data collected automatically by bedside monitoring devices in the Intensive Care Unit (ICU) and examines their effect on clinical decisions. METHODS Real-world data collected from 7688 patients admitted to the general ICU in a tertiary referral hospital over seven years was retrospectively analyzed. Data quality defect detection methods that use time-series analysis techniques identified two types of data quality defects: (a) completeness: the extent of non-missing values, and (b) validity: the extent of non-extreme values within the continuous range of values. Data quality defects were compared to five scenarios of medication and procedure prescriptions that are common in ICU settings: Blood-pressure reduction, blood-pressure elevation, anesthesia medications, intubation procedures, and muscle relaxant medications. RESULTS Results from a logistic regression revealed a strong connection between data quality and the clinical interventions examined: lower validity level increased the likelihood of prescription decisions for all five scenarios, and lower completeness level increased the likelihood of prescription decisions for some scenarios. DISCUSSION The results highlight the possible effect of data quality defects on physicians' decisions. Lower validity of certain key clinical parameters, and in some scenarios lower completeness, correlated with stronger tendency to prescribe medications or perform invasive procedures. CONCLUSIONS Data quality defects in clinical data affect decision making even without practitioners' awareness. Thus, it is important to emphasize these effects to ICU staff, as well as to medical device manufacturers.
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Affiliation(s)
- Oren Kramer
- Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel
| | - Adir Even
- Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel
| | - Idit Matot
- Tel-Aviv Medical Center, Tel-Aviv, Israel
| | | | - Yuval Bitan
- Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel.
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Abstract
This article explores the role of human factors engineering in patient safety in surgery. The authors discuss the history and evolution of human factors and the role of human factors in patient safety and provide a description of human factors methods used to study and improve patient safety.
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Affiliation(s)
- Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8215, Los Angeles, CA 90048, USA
| | - Bruce L Gewertz
- Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8215, Los Angeles, CA 90048, USA
| | - Daniel Shouhed
- Department of Surgery, Cedars-Sinai Medical Center, 8635 West Third Street, West Medical Office Tower, Suite 650-W, Los Angeles, CA 90048, USA.
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Salahuddin L, Ismail Z, Abd Ghani MK, Mohd Aboobaider B, Hasan Basari AS. Exploring the contributing factors to workarounds to the hospital information system in Malaysian hospitals. J Eval Clin Pract 2020; 26:1416-1424. [PMID: 31863517 DOI: 10.1111/jep.13326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/10/2019] [Accepted: 11/13/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The objective of this study was to identify the factors influencing workarounds to the Hospital Information System (HIS) in Malaysian government hospitals. METHODS Semi-structured interviews were conducted among 31 medical doctors in three Malaysian government hospitals on the implementation of the Total Hospital Information System (THIS) between March and May 2015. A thematic qualitative analysis was performed on the resultant data to deduce the relevant themes. RESULTS Five themes emerged as the factors influencing workarounds to the HIS: (a) typing skills, (b) system usability, (c) computer resources, (d) workload, and (e) time. CONCLUSIONS This study provided the key factors as to why doctors were involved in workarounds during the implementation of the HIS. It is important to understand these factors in order to help mitigate work practices that can pose a threat to patient safety.
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Affiliation(s)
- Lizawati Salahuddin
- Centre for Advanced Computing Technology (C-ACT), Fakulti Teknologi Maklumat dan Komunikasi (FTMK), Universiti Teknikal Malaysia Melaka, Melaka, Malaysia
| | - Zuraini Ismail
- Advanced Informatics Department, Razak Faculty of Technology and Informatics, Universiti Teknologi Malaysia Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Mohd Khanapi Abd Ghani
- Centre for Advanced Computing Technology (C-ACT), Fakulti Teknologi Maklumat dan Komunikasi (FTMK), Universiti Teknikal Malaysia Melaka, Melaka, Malaysia
| | - Burhanuddin Mohd Aboobaider
- Centre for Advanced Computing Technology (C-ACT), Fakulti Teknologi Maklumat dan Komunikasi (FTMK), Universiti Teknikal Malaysia Melaka, Melaka, Malaysia
| | - Abd Samad Hasan Basari
- Centre for Advanced Computing Technology (C-ACT), Fakulti Teknologi Maklumat dan Komunikasi (FTMK), Universiti Teknikal Malaysia Melaka, Melaka, Malaysia
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Odberg KR, Hansen BS, Aase K, Wangensteen S. A work system analysis of the medication administration process in a Norwegian nursing home ward. APPLIED ERGONOMICS 2020; 86:103100. [PMID: 32342890 DOI: 10.1016/j.apergo.2020.103100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/20/2020] [Accepted: 03/19/2020] [Indexed: 06/11/2023]
Abstract
Nursing home patients often have multiple diagnoses and a high prevalence of polypharmacy and are at risk of experiencing adverse drug events. The study aims to explore the dynamic interactions of stakeholders and work system elements in the medication administration process in a nursing home ward. Data were collected using observations and interviews. A deductive content analysis led to a SEIPS-based process map and an accompanying work system analysis. The study increases knowledge of the complexity of the medication administration process by portraying the dynamic interactions between the major stakeholders in the work system, and the temporal flow of the activities involved. Secondly, it identifies facilitators and barriers in the work system linked to the medication administration process. Most barriers and facilitators are associated with the work system elements - tools & technology, organisation and tasks - and occur early in the medication administration process.
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Affiliation(s)
- Kristian Ringsby Odberg
- Norwegian University of Science and Technology (NTNU), Department of Health Sciences in Gjøvik, Norway.
| | | | - Karina Aase
- University of Stavanger, Department of Health Studies, Centre Director, SHARE - Centre for Resilience in Healthcare, Norway
| | - Sigrid Wangensteen
- Norwegian University of Science and Technology (NTNU), Department of Health Sciences in Gjøvik, Norway.
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Kim SH, Kwon J. How Do EHRs and a Meaningful Use Initiative Affect Breaches of Patient Information? INFORMATION SYSTEMS RESEARCH 2019. [DOI: 10.1287/isre.2019.0858] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Seung Hyun Kim
- School of Business, Yonsei University, Seoul 03722, Korea
| | - Juhee Kwon
- Department of Information Systems, College of Business, City University of Hong Kong, Hong Kong SAR, China
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Wright MC, Borbolla D, Waller RG, Del Fiol G, Reese T, Nesbitt P, Segall N. Critical care information display approaches and design frameworks: A systematic review and meta-analysis. J Biomed Inform 2019; 3:100041. [PMID: 31423485 PMCID: PMC6696941 DOI: 10.1016/j.yjbinx.2019.100041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 06/10/2019] [Accepted: 06/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To systematically review original user evaluations of patient information displays relevant to critical care and understand the impact of design frameworks and information presentation approaches on decision-making, efficiency, workload, and preferences of clinicians. METHODS We included studies that evaluated information displays designed to support real-time care decisions in critical care or anesthesiology using simulated tasks. We searched PubMed and IEEExplore from 1/1/1990 to 6/30/2018. The search strategy was developed iteratively with calibration against known references. Inclusion screening was completed independently by two authors. Extraction of display features, design processes, and evaluation method was completed by one and verified by a second author. RESULTS Fifty-six manuscripts evaluating 32 critical care and 22 anesthesia displays were included. Primary outcome metrics included clinician accuracy and efficiency in recognizing, diagnosing, and treating problems. Implementing user-centered design (UCD) processes, especially iterative evaluation and redesign, resulted in positive impact in outcomes such as accuracy and efficiency. Innovative display approaches that led to improved human-system performance in critical care included: (1) improving the integration and organization of information, (2) improving the representation of trend information, and (3) implementing graphical approaches to make relationships between data visible. CONCLUSION Our review affirms the value of key principles of UCD. Improved information presentation can facilitate faster information interpretation and more accurate diagnoses and treatment. Improvements to information organization and support for rapid interpretation of time-based relationships between related quantitative data is warranted. Designers and developers are encouraged to involve users in formal iterative design and evaluation activities in the design of electronic health records (EHRs), clinical informatics applications, and clinical devices.
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Affiliation(s)
- Melanie C. Wright
- Trinity Health, Livonia, MI, USA
- Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | - Damian Borbolla
- Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | | | | | - Thomas Reese
- Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Paige Nesbitt
- Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | - Noa Segall
- Anesthesiology, Duke University, Durham, NC, USA
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Faiola A, Papautsky EL, Isola M. Empowering the Aging with Mobile Health: A mHealth Framework for Supporting Sustainable Healthy Lifestyle Behavior. Curr Probl Cardiol 2019; 44:232-266. [DOI: 10.1016/j.cpcardiol.2018.06.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/18/2018] [Indexed: 11/25/2022]
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Pitts SI, Barasch N, Maslen AT, Thomas BA, Dorissaint LP, Decker KG, Kazi S, Yang Y, Chen AR. Understanding CancelRx: Results of End-to-End Functional Testing, Proactive Risk Assessment, and Pilot Implementation. Appl Clin Inform 2019; 10:336-347. [PMID: 31117135 DOI: 10.1055/s-0039-1688698] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND CancelRx allows prescribers to send electronic cancellation messages to pharmacies when medications are discontinued. Little is known about its functionality and impact on clinical workflows. OBJECTIVES To understand CancelRx functionality, its potential impact on workflows and medication safety risks, and to develop mitigating strategies for risks introduced by implementation. METHODS We conducted direct observations and semi-structured interviews to develop CancelRx use cases and assessed CancelRx in an end-to-end test environment, proactive risk assessment, and pilot implementation from April 16 to July 15, 2018. RESULTS E-cancellations were sent upon discontinuation of e-prescriptions written within the electronic health record (EHR), but not other medications (e.g., printed prescriptions) and could be initiated by nonprescribers. In our proactive risk assessment, CancelRx implementation eliminated five of seven failure modes in outpatient prescribing to Johns Hopkins pharmacies, but introduced new risks, including (1) failure to act if an e-cancellation was not sent or was unsuccessful; (2) failure to cancel all prescriptions for a medication; (3) errors in manual matching; and (4) erroneous medication cancellations. We identified potential mitigation strategies for these risks. During pilot implementation, 92.4% (428/463) of e-cancellations had confirmed approval by the receiving pharmacy, while 4.5% (21/463) were denied, and 3.0% (14/463) had no e-cancellation response. Among e-cancellations received by the pilot pharmacy, 1.7% (7/408) required manual matching by pharmacy staff. Based on performance in testing, 73.4% (340/463) of completed e-cancellations would be expected to generate an in-basket message, including 21 (6.2%) denials and 319/340 (93.8%) approvals with a note from the pharmacy. CONCLUSION CancelRx is an important functionality with the potential to decrease adverse events due to medication errors. However, changes in implementation in our EHR and pharmacy software and enhancements in the CancelRx standard are needed to maximize safety and usability. Further studies are needed to evaluate the impact of e-cancellation on medication safety.
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Affiliation(s)
- Samantha I Pitts
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Noah Barasch
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Andrew T Maslen
- Information Technology, Johns Hopkins Health System, Baltimore, Maryland, United States
| | - Bridgette A Thomas
- Pharmacy Services, Johns Hopkins Home Care Group, Baltimore, Maryland, United States
| | - Leonard P Dorissaint
- Information Technology, Johns Hopkins Health System, Baltimore, Maryland, United States
| | - Krista G Decker
- Department of Quality Management, Johns Hopkins Home Care Group, Baltimore, Maryland, United States
| | - Sadaf Kazi
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Yushi Yang
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Health System, Baltimore, Maryland, United States
| | - Allen R Chen
- Departments of Oncology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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10
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Ash JS, Singh H, Wright A, Chase D, Sittig DF. Essential activities for electronic health record safety: A qualitative study. Health Informatics J 2019; 26:3140-3151. [PMID: 30848694 DOI: 10.1177/1460458219833109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Electronic health record-caused safety risks are an unintended consequence of the implementation of clinical systems. To identify activities essential to assuring that the electronic health record is managed and used safely, we used the Rapid Assessment Process, a collection of qualitative methods. A multidisciplinary team conducted visits to five healthcare sites to learn about best practices. Although titles and roles were very different across sites, certain tasks considered necessary by our subjects were remarkably similar. We identified 10 groups of activities/tasks in three major areas. Area A, decision-making activities, included overseeing, planning, and reviewing to assure electronic health record safety. Area B, organizational learning activities, involved monitoring, testing, analyzing, and reporting. Finally, Area C, user-related activities, included training, communication, and building clinical decision support. To minimize electronic health record-related patient safety risks, leaders in healthcare organizations should ensure that these essential activities are performed.
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Affiliation(s)
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, USA
| | | | | | - Dean F Sittig
- University of Texas Health Science Center at Houston, USA
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Kumah-Crystal YA, Pirtle CJ, Whyte HM, Goode ES, Anders SH, Lehmann CU. Electronic Health Record Interactions through Voice: A Review. Appl Clin Inform 2018; 9:541-552. [PMID: 30040113 DOI: 10.1055/s-0038-1666844] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Usability problems in the electronic health record (EHR) lead to workflow inefficiencies when navigating charts and entering or retrieving data using standard keyboard and mouse interfaces. Voice input technology has been used to overcome some of the challenges associated with conventional interfaces and continues to evolve as a promising way to interact with the EHR. OBJECTIVE This article reviews the literature and evidence on voice input technology used to facilitate work in the EHR. It also reviews the benefits and challenges of implementation and use of voice technologies, and discusses emerging opportunities with voice assistant technology. METHODS We performed a systematic review of the literature to identify articles that discuss the use of voice technology to facilitate health care work. We searched MEDLINE and the Google search engine to identify relevant articles. We evaluated articles that discussed the strengths and limitations of voice technology to facilitate health care work. Consumer articles from leading technology publications addressing emerging use of voice assistants were reviewed to ascertain functionalities in existing consumer applications. RESULTS Using a MEDLINE search, we identified 683 articles that were reviewed for inclusion eligibility. The references of included articles were also reviewed. Sixty-one papers that discussed the use of voice tools in health care were included, of which 32 detailed the use of voice technologies in production environments. Articles were organized into three domains: Voice for (1) documentation, (2) commands, and (3) interactive response and navigation for patients. Of 31 articles that discussed usability attributes of consumer voice assistant technology, 12 were included in the review. CONCLUSION We highlight the successes and challenges of voice input technologies in health care and discuss opportunities to incorporate emerging voice assistant technologies used in the consumer domain.
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Affiliation(s)
- Yaa A Kumah-Crystal
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, United States
| | - Claude J Pirtle
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, United States
| | - Harrison M Whyte
- Department of Computer Science, Vanderbilt University College of Arts and Science, Vanderbilt University, Nashville, Tennessee, United States
| | - Edward S Goode
- Department of Computer Science, Vanderbilt University College of Arts and Science, Vanderbilt University, Nashville, Tennessee, United States
| | - Shilo H Anders
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, United States.,Department of Anesthesiology, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, United States
| | - Christoph U Lehmann
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, United States
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12
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Framework for Evaluating and Implementing Inpatient Portals: a Multi-stakeholder Perspective. J Med Syst 2018; 42:158. [DOI: 10.1007/s10916-018-1009-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/02/2018] [Indexed: 01/06/2023]
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Or C, Tong E, Tan J, Chan S. Exploring Factors Affecting Voluntary Adoption of Electronic Medical Records Among Physicians and Clinical Assistants of Small or Solo Private General Practice Clinics. J Med Syst 2018; 42:121. [PMID: 29845400 DOI: 10.1007/s10916-018-0971-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 05/18/2018] [Indexed: 10/16/2022]
Abstract
The health care reform initiative led by the Hong Kong government's Food and Health Bureau has started the implementation of an electronic sharing platform to provide an information infrastructure that enables public hospitals and private clinics to share their electronic medical records (EMRs) for improved access to patients' health care information. However, previous attempts to convince the private clinics to adopt EMRs to document health information have faced challenges, as the EMR adoption has been voluntary. The lack of electronic data shared by private clinics carries direct impacts to the efficacy of electronic record sharing between public and private healthcare providers. To increase the likelihood of buy-in, it is essential to proactively identify the users' and organizations' needs and capabilities before large-scale implementation. As part of the reform initiative, this study examined factors affecting the adoption of EMRs in small or solo private general practice clinics, by analyzing the experiences and opinions of the physicians and clinical assistants during the pilot implementation of the technology, with the purpose to learn from it before full-scale rollout. In-depth, semistructured interviews were conducted with 23 physicians and clinical assistants from seven small or solo private general practice clinics to evaluate their experiences, expectations, and opinions regarding the deployment of EMRs. Interview transcripts were content analyzed to identify key factors. Factors affecting the adoption of EMRs to record and manage health care information were identified as follows: system interface design; system functions; stability and reliability of hardware, software, and computing networks; financial and time costs; task and outcome performance, work practice, and clinical workflow; physical space in clinics; trust in technology; users' information technology literacy; training and technical support; and social and organizational influences. The factors are interrelated with the others. The adoption factors identified are multifaceted, ranging from technological characteristics, clinician-technology interactions, skills and knowledge, and the user-workflow-technology fit. Other findings, which have been relatively underrepresented in previous studies, contribute unique insights about the influence of work and social environment on the adoption of EMRs, including limited clinic space and the effects of physicians' decision to use the technology on clinical staffs' adoption decisions. Potential strategies to address the concerns, overcome adoption barriers, and define relevant policies are discussed.
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Affiliation(s)
- Calvin Or
- Department of Industrial & Manufacturing Systems Engineering, The University of Hong Kong, Pokfulam, Hong Kong.
| | - Ellen Tong
- Health Informatics Department, Hong Kong Hospital Authority, Kowloon, Hong Kong
| | - Joseph Tan
- DeGroote School of Business, McMaster University, Hamilton, ON, Canada
| | - Summer Chan
- Health Informatics Department, Hong Kong Hospital Authority, Kowloon, Hong Kong
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Abstract
OBJECTIVES To provide an overview of the history of electronic health policy and identify significant laws that influence health informatics. DATA SOURCES US Department of Health and Human Services. CONCLUSION The development of health information technology has influenced the process for delivering health care. Public policy and regulations are an important part of health informatics and establish the structure of electronic health systems. Regulatory bodies of the government initiate policies to ease the execution of electronic health record implementation. These same bureaucratic entities regulate the system to protect the rights of the patients and providers. IMPLICATIONS FOR NURSING PRACTICE Nurses should have an overall understanding of the system behind health informatics and be able to advocate for change. Nurses can utilize this information to optimize the use of health informatics and campaign for safe, effective, and efficient health information technology.
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Myers RB, Jones SL, Sittig DF. Review of Reported Clinical Information System Adverse Events in US Food and Drug Administration Databases. Appl Clin Inform 2017; 2:63-74. [PMID: 21938265 DOI: 10.4338/aci-2010-11-ra-0064] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND: The US FDA has been collecting information on medical devices involved in significant adverse advents since 1984. These reports have been used by researchers to advise clinicians on potential risks and complications of using these devices. OBJECTIVE: Research adverse events related to the use of Clinical Information Systems (CIS) as reported in FDA databases. METHODS: Three large, national, adverse event medical device databases were examined for reports pertaining to CIS. RESULTS: One hundred and twenty unique reports (from over 1.4 million reports) were found, representing 32 manufacturers. The manifestations of these adverse events included: missing or incorrect data, data displayed for the wrong patient, chaos during system downtime and system unavailable for use. Analysis of these reports illustrated events associated with system design, implementation, use, and support. CONCLUSION: The identified causes can be used by manufacturers to improve their products and by clinical facilities and providers to adjust their workflow and implementation processes appropriately. The small number of reports found indicates a need to raise awareness regarding publicly available tools for documenting problems with CIS and for additional reporting and dialog between manufacturers, organizations, and users.
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Affiliation(s)
- Risa B Myers
- University of Texas School of Biomedical Informatics, Houston, TX
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16
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Mozaffar H, Cresswell KM, Williams R, Bates DW, Sheikh A. Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study. BMJ Qual Saf 2017; 26:722-733. [DOI: 10.1136/bmjqs-2016-005879] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 01/11/2017] [Accepted: 01/16/2017] [Indexed: 11/04/2022]
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Carayon P, Du S, Brown R, Cartmill R, Johnson M, Wetterneck TB. EHR-related medication errors in two ICUs. J Healthc Risk Manag 2017; 36:6-15. [PMID: 28099789 PMCID: PMC8311113 DOI: 10.1002/jhrm.21259] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The objective of this study was to describe the frequency, potential harm, and nature of electronic health record (EHR)-related medication errors in intensive care units (ICUs). Using a secondary data analysis of a large database of medication safety events collected in a study on EHR technology in ICUs, we assessed the EHR relatedness of a total of 1622 potential preventable adverse drug events (ADEs) identified in a sample of 624 patients in 2 ICUs of a medical center. Thirty-four percent of the medication events were found to be EHR related. The EHR-related medication events had greater potential for more serious patient harm and occurred more frequently at the ordering stage as compared to non-EHR-related events. Examples of EHR-related events included orders with omitted information and duplicate orders. The list of EHR-related medication errors can be used by health care delivery organizations to monitor implementation and use of the technology and its impact on patient safety. Health information technology (IT) vendors can use the list to examine whether their technology can mitigate or reduce EHR-related medication errors.
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Barnett ML, Mehrotra A, Frolkis JP, Spinks M, Steiger C, Hehir B, Greenberg JO, Singh H. Implementation Science Workshop: Implementation of an Electronic Referral System in a Large Academic Medical Center. J Gen Intern Med 2016; 31:343-52. [PMID: 26556594 PMCID: PMC4762816 DOI: 10.1007/s11606-015-3516-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Michael L Barnett
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Health Care Policy, Harvard Medical School, 180A Longwood Ave., Boston, MA, 02115, USA.
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, 180A Longwood Ave., Boston, MA, 02115, USA
| | - Joseph P Frolkis
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Casey Steiger
- Brigham and Women's Physicians Organization, Boston, MA, USA
| | - Brandon Hehir
- Brigham and Women's Physicians Organization, Boston, MA, USA
| | - Jeffrey O Greenberg
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Brigham and Women's Physicians Organization, Boston, MA, USA
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
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Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf 2015; 24:103-10. [PMID: 25589094 PMCID: PMC4316850 DOI: 10.1136/bmjqs-2014-003675] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Diagnostic errors are major contributors to harmful patient outcomes, yet they remain a relatively understudied and unmeasured area of patient safety. Although they are estimated to affect about 12 million Americans each year in ambulatory care settings alone, both the conceptual and pragmatic scientific foundation for their measurement is under-developed. Health care organizations do not have the tools and strategies to measure diagnostic safety and most have not integrated diagnostic error into their existing patient safety programs. Further progress toward reducing diagnostic errors will hinge on our ability to overcome measurement-related challenges. In order to lay a robust groundwork for measurement and monitoring techniques to ensure diagnostic safety, we recently developed a multifaceted framework to advance the science of measuring diagnostic errors (The Safer Dx framework). In this paper, we describe how the framework serves as a conceptual foundation for system-wide safety measurement, monitoring and improvement of diagnostic error. The framework accounts for the complex adaptive sociotechnical system in which diagnosis takes place (the structure), the distributed process dimensions in which diagnoses evolve beyond the doctor's visit (the process) and the outcomes of a correct and timely "safe diagnosis" as well as patient and health care outcomes (the outcomes). We posit that the Safer Dx framework can be used by a variety of stakeholders including researchers, clinicians, health care organizations and policymakers, to stimulate both retrospective and more proactive measurement of diagnostic errors. The feedback and learning that would result will help develop subsequent interventions that lead to safer diagnosis, improved value of health care delivery and improved patient outcomes.
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Affiliation(s)
- Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Dean F Sittig
- University of Texas School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, Texas, USA
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Menon S, Smith MW, Sittig DF, Petersen NJ, Hysong SJ, Espadas D, Modi V, Singh H. How context affects electronic health record-based test result follow-up: a mixed-methods evaluation. BMJ Open 2014; 4:e005985. [PMID: 25387758 PMCID: PMC4244393 DOI: 10.1136/bmjopen-2014-005985] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Electronic health record (EHR)-based alerts can facilitate transmission of test results to healthcare providers, helping ensure timely and appropriate follow-up. However, failure to follow-up on abnormal test results (missed test results) persists in EHR-enabled healthcare settings. We aimed to identify contextual factors associated with facility-level variation in missed test results within the Veterans Affairs (VA) health system. DESIGN, SETTING AND PARTICIPANTS Based on a previous survey, we categorised VA facilities according to primary care providers' (PCPs') perceptions of low (n=20) versus high (n=20) risk of missed test results. We interviewed facility representatives to collect data on several contextual factors derived from a sociotechnical conceptual model of safe and effective EHR use. We compared these factors between facilities categorised as low and high perceived risk, adjusting for structural characteristics. RESULTS Facilities with low perceived risk were significantly more likely to use specific strategies to prevent alerts from being lost to follow-up (p=0.0114). Qualitative analysis identified three high-risk scenarios for missed test results: alerts on tests ordered by trainees, alerts 'handed off' to another covering clinician (surrogate clinician), and alerts on patients not assigned in the EHR to a PCP. Test result management policies and procedures to address these high-risk situations varied considerably across facilities. CONCLUSIONS Our study identified several scenarios that pose a higher risk for missed test results in EHR-based healthcare systems. In addition to implementing provider-level strategies to prevent missed test results, healthcare organisations should consider implementing monitoring systems to track missed test results.
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Affiliation(s)
- Shailaja Menon
- Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA
| | - Michael W Smith
- Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA
| | - Dean F Sittig
- Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA
| | - Nancy J Petersen
- University of Texas School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, Texas, USA
| | - Sylvia J Hysong
- Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA
| | - Donna Espadas
- Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA
| | - Varsha Modi
- Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA
| | - Hardeep Singh
- Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety, the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Houston, Texas, USA
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Ben-Zion R, Pliskin N, Fink L. Critical Success Factors for Adoption of Electronic Health Record Systems: Literature Review and Prescriptive Analysis. INFORMATION SYSTEMS MANAGEMENT 2014. [DOI: 10.1080/10580530.2014.958024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Smith MW, Ash JS, Sittig DF, Singh H. Resilient Practices in Maintaining Safety of Health Information Technologies. JOURNAL OF COGNITIVE ENGINEERING AND DECISION MAKING 2014; 8:265-282. [PMID: 25866492 PMCID: PMC4361460 DOI: 10.1177/1555343414534242] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Electronic health record systems (EHRs) can improve safety and reliability of health care, but they can also introduce new vulnerabilities by failing to accommodate changes within a dynamic EHR-enabled health care system. Continuous assessment and improvement is thus essential for achieving resilience in EHR-enabled health care systems. Given the rapid adoption of EHRs by many organizations that are still early in their experiences with EHR safety, it is important to understand practices for maintaining resilience used by organizations with a track record of success in EHR use. We conducted interviews about safety practices with 56 key informants (including information technology managers, chief medical information officers, physicians, and patient safety officers) at two large health care systems recognized as leaders in EHR use. We identified 156 references to resilience-related practices from 41 informants. Framework analysis generated five categories of resilient practices: (a) sensitivity to dynamics and interdependencies affecting risks, (b) basic monitoring and responding practices, (c) management of practices and resources for monitoring and responding, (d) sensitivity to risks beyond the horizon, and (e) reflecting on risks with the safety and quality control process itself. The categories reflect three functions that facilitate resilience: reflection, transcending boundaries, and involving sharp-end practitioners in safety management.
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Affiliation(s)
| | - Joan S Ash
- Oregon Health and Science University, Portland
| | | | - Hardeep Singh
- Michael E. DeBakey VA Medical Center, Houston, Texas
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Carayon P, Wetterneck TB, Rivera-Rodriguez AJ, Hundt AS, Hoonakker P, Holden R, Gurses AP. Human factors systems approach to healthcare quality and patient safety. APPLIED ERGONOMICS 2014; 45:14-25. [PMID: 23845724 PMCID: PMC3795965 DOI: 10.1016/j.apergo.2013.04.023] [Citation(s) in RCA: 318] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 04/24/2013] [Indexed: 05/03/2023]
Abstract
Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety.
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Affiliation(s)
- Pascale Carayon
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 1550 Engineering Drive, Madison, WI 53706, USA; Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1550 Engineering Drive, Madison, WI 53706, USA.
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Paez K, Roper RA, Andrews RM. Health information technology and hospital patient safety: a conceptual model to guide research. Jt Comm J Qual Patient Saf 2013; 39:415-25. [PMID: 24147353 DOI: 10.1016/s1553-7250(13)39055-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The literature indicates that health information technology (IT) use may lead to some gains in the quality and safety of care in some situations but provides little insight into this variability in the results that has been found. The inconsistent findings point to the need for a conceptual model that will guide research in sorting out the complex relationships between health IT and the quality and safety of care. METHODS A conceptual model was developed that describes how specific health IT functions could affect different types of inpatient safety errors and that include contextual factors that influence successful health IT implementation. The model was applied to a readily available patient safety measure and nationwide data (2009 AHA Annual Survey Information Technology Supplement and 2009 Healthcare Cost and Utilization Project State Inpatient Databases). FINDINGS The model was difficult to operationalize because (1) available health IT adoption data did not characterize health IT features and extent of usage, and (2) patient safety measures did not elucidate the process failures leading to safety-related outcomes. The sample patient safety measure--Postoperative Physiologic and Metabolic Derangement Rate--was not significantly related to self-reported health IT capabilities when adjusted for hospital structural characteristics. CONCLUSION These findings illustrate the critical need for collecting data that are germane to health IT and the possible mechanisms by which health IT may affect inpatient safety. Well-defined and sufficiently granular measures of provider's correct use of health IT functions, the contextual factors surrounding health IT use, and patient safety errors leading to health care-associated conditions are needed to illuminate the impact of health IT on patient safety.
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Affiliation(s)
- Kathryn Paez
- American Institutes for Research, Silver Spring, Maryland, USA.
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Holden RJ, Carayon P, Gurses AP, Hoonakker P, Hundt AS, Ozok AA, Rivera-Rodriguez AJ. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. ERGONOMICS 2013; 56:1669-86. [PMID: 24088063 PMCID: PMC3835697 DOI: 10.1080/00140139.2013.838643] [Citation(s) in RCA: 592] [Impact Index Per Article: 53.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Healthcare practitioners, patient safety leaders, educators and researchers increasingly recognise the value of human factors/ergonomics and make use of the discipline's person-centred models of sociotechnical systems. This paper first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, 'SEIPS 2.0'. SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement and adaptation. The concept of configuration highlights the dynamic, hierarchical and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at 'a moment in time'. Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed.
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Affiliation(s)
- Richard J. Holden
- Assistant Professor, Department of Medicine, Division of General Internal Medicine & Public Health, Department of Biomedical Informatics Vanderbilt University School of Medicine, Phone: +1-615-936-4343, Fax: +1-615-936-7373, Center for Research and Innovation in Systems Safety, 719 Medical Arts Building, 1211 21st Avenue S, Nashville, TN, 37212
| | - Pascale Carayon
- Procter & Gamble Bascom Professor in Total Quality, Department of Industrial and Systems Engineering, Director of the Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 3126 Engineering Centers Building, 1550 Engineering Drive, Madison, WI 53706 - USA, tel: +1-608-265-0503 or +1-608-263-2520, fax: +1-608-263-1425
| | - Ayse P. Gurses
- Associate Professor, Armstrong Institute for Patient Safety and Quality, Department of Anesthesiology and Critical Care Medicine, Division of Health Sciences Informatics, School of Medicine, Department of Health Policy and Management, Bloomberg School of Public Health, Department of Civil Engineering, Whiting School of Engineering, The Johns Hopkins University, 750 E. Pratt St. 15Floor, Baltimore, MD 21202, Phone: +1-410-637-4387
| | - Peter Hoonakker
- Research Scientist and Associate Director of Research, Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 3132 Engineering Centers Building, 1550 Engineering Drive, Madison, WI 53706 – USA, Phone: +1-608-658 0837, Fax: +1-608-263-1425
| | - Ann Schoofs Hundt
- Associate Scientist and Associate Director of Education, Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 3132 Engineering Centers Building, 1550 Engineering Drive, Madison, WI 53706 – USA, Phone: +1-608-262-9100, Fax: +1-608-263-1425
| | - A. Ant Ozok
- Associate Professor, Department of Information Systems, UMBC, Adjunct Associate Professor, Department of Anesthesiology, Visiting Associate Professor, The Armstrong Institute of Patient Safety and Quality, School of Medicine, The Johns Hopkins University, 1000 Hilltop Circle, Baltimore, MD 21250, Phone : +1-410-455-8627, Fax : +1-410-455-1073
| | - A. Joy Rivera-Rodriguez
- Assistant Professor, Department of Industrial Engineering, Clemson University, Phone: +1-864-656-3114, Fax: +1-864-656-0795, 130-C Freeman Hall, Box 340920 Clemson, SC 29631
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Middleton B, Bloomrosen M, Dente MA, Hashmat B, Koppel R, Overhage JM, Payne TH, Rosenbloom ST, Weaver C, Zhang J. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. J Am Med Inform Assoc 2013; 20:e2-8. [PMID: 23355463 PMCID: PMC3715367 DOI: 10.1136/amiajnl-2012-001458] [Citation(s) in RCA: 338] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In response to mounting evidence that use of electronic medical record systems may cause unintended consequences, and even patient harm, the AMIA Board of Directors convened a Task Force on Usability to examine evidence from the literature and make recommendations. This task force was composed of representatives from both academic settings and vendors of electronic health record (EHR) systems. After a careful review of the literature and of vendor experiences with EHR design and implementation, the task force developed 10 recommendations in four areas: (1) human factors health information technology (IT) research, (2) health IT policy, (3) industry recommendations, and (4) recommendations for the clinician end-user of EHR software. These AMIA recommendations are intended to stimulate informed debate, provide a plan to increase understanding of the impact of usability on the effective use of health IT, and lead to safer and higher quality care with the adoption of useful and usable EHR systems.
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Affiliation(s)
- Blackford Middleton
- Clinical Informatics Research and Development, Partners HealthCare System, Harvard Medical School, Wellesley, Massachusetts 02481, USA.
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Jones JB, Stewart WF, Darer JD, Sittig DF. Beyond the threshold: real-time use of evidence in practice. BMC Med Inform Decis Mak 2013; 13:47. [PMID: 23587225 PMCID: PMC3639800 DOI: 10.1186/1472-6947-13-47] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 04/05/2013] [Indexed: 02/08/2023] Open
Abstract
In two landmark reports on Quality and Information Technology, the Institute of Medicine described a 21st century healthcare delivery system that would improve the quality of care while reducing its costs. To achieve the improvements envisioned in these reports, it is necessary to increase the efficiency and effectiveness of the clinical decision support that is delivered to clinicians through electronic health records at the point of care. To make these dramatic improvements will require significant changes to the way in which clinical practice guidelines are developed, incorporated into existing electronic health records (EHR), and integrated into clinicians' workflow at the point of care. In this paper, we: 1) discuss the challenges associated with translating evidence to practice; 2) consider what it will take to bridge the gap between the current limits to use of CPGs and expectations for their meaningful use at the point of care in practices with EHRs; 3) describe a framework that underlies CDS systems which, if incorporated in the development of CPGs, can be a means to bridge this gap, 4) review the general types and adoption of current CDS systems, and 5) describe how the adoption of EHRs and related technologies will directly influence the content and form of CPGs. Achieving these objectives should result in improvements in the quality and reductions in the cost of healthcare, both of which are necessary to ensure a 21st century delivery system that consistently provides safe and effective care to all patients.
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Affiliation(s)
- James B Jones
- Geisinger Center for Health Research, Danville, PA, USA
| | | | | | - Dean F Sittig
- University of Texas Health Science Center – Memorial Hermann Center for Healthcare Quality & Safety, School of Biomedical Informatics, Houston, TX, USA
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Singh H, Ash JS, Sittig DF. Safety Assurance Factors for Electronic Health Record Resilience (SAFER): study protocol. BMC Med Inform Decis Mak 2013; 13:46. [PMID: 23587208 PMCID: PMC3639028 DOI: 10.1186/1472-6947-13-46] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 02/06/2013] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Implementation and use of electronic health records (EHRs) could lead to potential improvements in quality of care. However, the use of EHRs also introduces unique and often unexpected patient safety risks. Proactive assessment of risks and vulnerabilities can help address potential EHR-related safety hazards before harm occurs; however, current risk assessment methods are underdeveloped. The overall objective of this project is to develop and validate proactive assessment tools to ensure that EHR-enabled clinical work systems are safe and effective. METHODS/DESIGN This work is conceptually grounded in an 8-dimension model of safe and effective health information technology use. Our first aim is to develop self-assessment guides that can be used by health care institutions to evaluate certain high-risk components of their EHR-enabled clinical work systems. We will solicit input from subject matter experts and relevant stakeholders to develop guides focused on 9 specific risk areas and will subsequently pilot test the guides with individuals representative of likely users. The second aim will be to examine the utility of the self-assessment guides by beta testing the guides at selected facilities and conducting on-site evaluations. Our multidisciplinary team will use a variety of methods to assess the content validity and perceived usefulness of the guides, including interviews, naturalistic observations, and document analysis. The anticipated output of this work will be a series of self-administered EHR safety assessment guides with clear, actionable, checklist-type items. DISCUSSION Proactive assessment of patient safety risks increases the resiliency of health care organizations to unanticipated hazards of EHR use. The resulting products and lessons learned from the development of the assessment guides are expected to be helpful to organizations that are beginning the EHR selection and implementation process as well as those that have already implemented EHRs. Findings from our project, currently underway, will inform future efforts to validate and implement tools that can be used by health care organizations to improve the safety of EHR-enabled clinical work systems.
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Affiliation(s)
- Hardeep Singh
- Houston VA HSR&D Center of Excellence, the Michael E DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA.
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Esquivel A, Sittig DF, Murphy DR, Singh H. Improving the effectiveness of electronic health record-based referral processes. BMC Med Inform Decis Mak 2012; 12:107. [PMID: 22973874 PMCID: PMC3492108 DOI: 10.1186/1472-6947-12-107] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 08/24/2012] [Indexed: 02/08/2023] Open
Abstract
Electronic health records are increasingly being used to facilitate referral communication in the outpatient setting. However, despite support by technology, referral communication between primary care providers and specialists is often unsatisfactory and is unable to eliminate care delays. This may be in part due to lack of attention to how information and communication technology fits within the social environment of health care. Making electronic referral communication effective requires a multifaceted “socio-technical” approach. Using an 8-dimensional socio-technical model for health information technology as a framework, we describe ten recommendations that represent good clinical practices to design, develop, implement, improve, and monitor electronic referral communication in the outpatient setting. These recommendations were developed on the basis of our previous work, current literature, sound clinical practice, and a systems-based approach to understanding and implementing health information technology solutions. Recommendations are relevant to system designers, practicing clinicians, and other stakeholders considering use of electronic health records to support referral communication.
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Affiliation(s)
- Adol Esquivel
- Department of Clinical Effectiveness and Performance Measurement, St. Luke’s Episcopal Health System, Houston, TX, USA
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An enhancement of the role-based access control model to facilitate information access management in context of team collaboration and workflow. J Biomed Inform 2012; 45:1084-107. [PMID: 22732236 DOI: 10.1016/j.jbi.2012.06.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 05/29/2012] [Accepted: 06/06/2012] [Indexed: 11/22/2022]
Abstract
Although information access control models have been developed and applied to various applications, few of the previous works have addressed the issue of managing information access in the combined context of team collaboration and workflow. To facilitate this requirement, we have enhanced the Role-Based Access Control (RBAC) model through formulating universal constraints, defining bridging entities and contributing attributes, extending access permissions to include workflow contexts, synthesizing a role-based access delegation model to target on specific objects, and developing domain ontologies as instantiations of the general model to particular applications. We have successfully applied this model to the New York State HIV Clinical Education Initiative (CEI) project to address the specific needs of information management in collaborative processes. An initial evaluation has shown this model achieved a high level of agreement with an existing system when applied to 4576 cases (kappa=0.801). Comparing to a reference standard, the sensitivity and specificity of the enhanced RBAC model were at the level of 97-100%. These results indicate that the enhanced RBAC model can be effectively used for information access management in context of team collaboration and workflow to coordinate clinical education programs. Future research is required to incrementally develop additional types of universal constraints, to further investigate how the workflow context and access delegation can be enriched to support the various needs on information access management in collaborative processes, and to examine the generalizability of the enhanced RBAC model for other applications in clinical education, biomedical research, and patient care.
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Creating an oversight infrastructure for electronic health record-related patient safety hazards. J Patient Saf 2012; 7:169-74. [PMID: 22080284 DOI: 10.1097/pts.0b013e31823d8df0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Electronic health records (EHRs) have potential quality and safety benefits. However, reports of EHR-related safety hazards are now emerging. The Office of the National Coordinator for Health Information Technology recently sponsored an Institute of Medicine committee to evaluate how health information technology use affects patient safety. In this article, we propose the creation of a national EHR oversight program to provide dedicated surveillance of EHR-related safety hazards and to promote learning from identified errors, close calls, and adverse events. The program calls for data gathering, investigation/analysis, and regulatory components. The first 2 functions will depend on institution-level EHR safety committees that will investigate all known EHR-related adverse events and near-misses and report them nationally using standardized methods. These committees should also perform routine safety self-assessments to proactively identify new risks. Nationally, we propose the long-term creation of a centralized, nonpartisan board with an appropriate legal and regulatory infrastructure to ensure the safety of EHRs. We discuss the rationale of the proposed oversight program and its potential organizational components and functions. These include mechanisms for robust data collection and analyses of all safety concerns using multiple methods that extend beyond reporting, multidisciplinary investigation of selected high-risk safety events, and enhanced coordination with other national agencies to facilitate broad dissemination of hazards information. Implementation of this proposed infrastructure can facilitate identification of EHR-related adverse events and errors and potentially create a safer and more effective EHR-based health care delivery system.
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Ten strategies to improve management of abnormal test result alerts in the electronic health record. J Patient Saf 2012; 6:121-3. [PMID: 20563228 DOI: 10.1097/pts.0b013e3181ddf652] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
OBJECTIVE It is the objective of this article to provide a guide to health care providers adopting computerized prescriber order entry (CPOE) and to explain recent developments of important concepts and initiatives such as "meaningful use" that will have significant impact on successful implementation of CPOE. The specific goals are to discuss key concepts relating to the NEW ARRA/HITECH-EHR meaningful use criteria and its relevance to CPOE Safe Practice and medication safety, summarize and update the recent scientific evidence evaluating CPOE, present the new 2010 CPOE safe practice, and suggest ways the CPOE safe practice may be expanded and harmonized with the new EHR meaningful use criteria. METHODS This article evaluates the latest published studies in the field of CPOE and reexamines the objectives, the requirements for achieving these objectives, and evidence of efficacy for this practice. It reviews relevant issues of medication safety, the likely impact of CPOE, the efficacy of CPOE in various studies, key measures of impact of the practice, and important implementation issues. The 2010 updates to the National Quality Forum CPOE practice are also reviewed with support from the evidentiary base. RESULTS This paper has presented an update to the National Quality Forum Safe Practice on CPOE for 2010. Although the practice itself has not changed, the scientific evidence of the impact of CPOE on medication safety and quality of care continues to accumulate. However, the adoption of CPOE by hospitals in the United States remains very low, as low as 6% in 1 study. CONCLUSIONS The adoption of CPOE has been low despite increasing evidence that hospital patients are still experiencing significant rates of preventable adverse drug events. This low adoption rate will likely be impacted by the new ARRA/HITECH legislation and the meaningful use concept.
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Notifications received by primary care practitioners in electronic health records: a taxonomy and time analysis. Am J Med 2012; 125:209.e1-7. [PMID: 22269625 DOI: 10.1016/j.amjmed.2011.07.029] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 07/22/2011] [Accepted: 07/25/2011] [Indexed: 02/05/2023]
Abstract
BACKGROUND Asynchronous electronic health record (EHR)-based alerts used to notify practitioners via an inbox-like format rather than through synchronous computer "pop-up" messages are understudied. Our objective was to create an asynchronous alert taxonomy and measure the impact of different alert types on practitioner workload. METHODS We quantified and categorized asynchronous alerts according to the information they conveyed and conducted a time-motion analysis to assess practitioner workload. We reviewed alert information transmitted to all 47 primary care practitioners (PCPs) at a large, tertiary care Veterans Affairs facility over 4 evenly spaced 28-day periods. An interdisciplinary team used content analysis to categorize alerts according to their conveyed information. We then created an alert taxonomy and used it to calculate the mean number of alerts of each type PCPs received each day. We conducted a time-motion study of 26 PCPs while they processed their alerts. We used these data to estimate the uninterrupted time practitioners spend processing alerts each day. RESULTS We extracted 295,792 asynchronously generated alerts and created a taxonomy of 33 alert types categorized under 6 major categories: Test Results, Referrals, Note-Based Communication, Order Status, Patient Status Changes, and Incomplete Task Reminders. PCPs received a mean of 56.4 alerts/day containing new information. Based on 749 observed alert processing episodes, practitioners spent an estimated average of 49 minutes/day processing their alerts. CONCLUSIONS PCPs receive a large number of EHR-based asynchronous alerts daily and spend significant time processing them. The utility of transmitting large quantities and varieties of alerts to PCPs warrants further investigation.
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Abstract
The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is described and selected research and practical applications are presented.
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Affiliation(s)
- Pascale Carayon
- Center for Quality and Productivity Improvement and Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1550 Engineering Drive, Madison, WI 53706, USA
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Abstract
OBJECTIVE : This study aimed to evaluate the use of a shared electronic primary health care record (EHR) to assist with medicines reconciliation in the hospital from admission to discharge. METHODS : This is a prospective cross-sectional, comparison evaluation for 2 phases, in a short-term elderly admissions ward in the United Kingdom. In phase 1, full reconciliation of the medication history was attempted, using conventional methods, before accessing the EHR, and then the EHR was used to verify the reconciliation. In phase 2, the EHR was the initial method of retrieving the medication history-validated by conventional methods. RESULTS : Where reconciliation was led by conventional methods, and before any access to the EHR was attempted, 28 (28%) of hospital prescriptions were found to contain errors. Of 99 prescriptions subsequently checked using the EHR, only 50 (50%) matched the EHR. Of the remainder, 25% of prescriptions contained errors when verified by the EHR. However, 26% of patients had an incorrect list of current medications on the EHR.Using the EHR as the primary method of reconciliation, 33 (32%) of 102 prescriptions matched the EHR. Of those that did not match, 39 (38%) of prescriptions were found to contain errors. Furthermore, 37 (36%) of patients had an incorrect list of current medications on the EHR.The most common error type on the discharge prescription was drug omission; and on the EHR, wrong drug. Common potentially serious errors were related to unidentified allergies and adverse drug reactions. CONCLUSIONS : The EHR can reduce medication errors. However, the EHR should be seen as one of a range of information sources for reconciliation; the primary source being the patient or their carer. Both primary care and hospital clinicians should have read-and-write access to the EHR to reduce errors at care transitions. We recommend further evaluation studies.
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Kuo AMH. Opportunities and challenges of cloud computing to improve health care services. J Med Internet Res 2011; 13:e67. [PMID: 21937354 PMCID: PMC3222190 DOI: 10.2196/jmir.1867] [Citation(s) in RCA: 281] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 08/10/2011] [Accepted: 08/25/2011] [Indexed: 11/13/2022] Open
Abstract
Cloud computing is a new way of delivering computing resources and services. Many managers and experts believe that it can improve health care services, benefit health care research, and change the face of health information technology. However, as with any innovation, cloud computing should be rigorously evaluated before its widespread adoption. This paper discusses the concept and its current place in health care, and uses 4 aspects (management, technology, security, and legal) to evaluate the opportunities and challenges of this computing model. Strategic planning that could be used by a health organization to determine its direction, strategy, and resource allocation when it has decided to migrate from traditional to cloud-based health services is also discussed.
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Affiliation(s)
- Alex Mu-Hsing Kuo
- School of Health Information Science, University of Victoria, Victoria, BC, Canada.
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Sittig DF, Singh H. Defining health information technology-related errors: new developments since to err is human. ACTA ACUST UNITED AC 2011; 171:1281-4. [PMID: 21788544 DOI: 10.1001/archinternmed.2011.327] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Despite the promise of health information technology (HIT), recent literature has revealed possible safety hazards associated with its use. The Office of the National Coordinator for HIT recently sponsored an Institute of Medicine committee to synthesize evidence and experience from the field on how HIT affects patient safety. To lay the groundwork for defining, measuring, and analyzing HIT-related safety hazards, we propose that HIT-related error occurs anytime HIT is unavailable for use, malfunctions during use, is used incorrectly by someone, or when HIT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted. These errors, or the decisions that result from them, significantly increase the risk of adverse events and patient harm. We describe how a sociotechnical approach can be used to understand the complex origins of HIT errors, which may have roots in rapidly evolving technological, professional, organizational, and policy initiatives.
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Affiliation(s)
- Dean F Sittig
- University of Texas–Memorial Hermann Center for Healthcare Quality & Safety, National Center for Cognitive Informatics and Decision Making, School of Biomedical Informatics, University of Texas Health Sciences Center, Houston, TX 77030, USA.
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Wetterneck TB, Lapin JA, Krueger DJ, Holman GT, Beasley JW, Karsh BT. Development of a primary care physician task list to evaluate clinic visit workflow. BMJ Qual Saf 2011; 21:47-53. [PMID: 21896667 DOI: 10.1136/bmjqs-2011-000067] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Interventions designed to improve the delivery of primary care, including Patient-Centered Medical Homes and electronic health records, require an understanding of clinical workflow to be successfully implemented. However, there is a lack of tools to describe and study primary care physician workflow. We developed a comprehensive list of primary care physician tasks that occur during a face-to-face patient visit. METHODS A validated list of tasks performed by primary care physicians during patient clinic visits was developed from a secondary data analysis of observation data from two studies evaluating primary care workflow. Thirty primary care physicians participated from a convenience sample of 17 internal medicine and family medicine clinics in Wisconsin and Iowa across rural and urban settings and community and academic settings. RESULTS The final task list has 12 major tasks, 189 subtasks, and 191 total tasks. The major tasks are: Enter Room, Gather Information from Patient, Review Patient Information, Document Patient Information, Perform, Recommend / Discuss Treatment Options, Look Up, Order, Communicate, Print / Give Patient (advice, instructions), Appointment Wrap-up, and Leave Room. Additional subcodes note use of paper or EHR and the presence of a caregiver or medical student. CONCLUSIONS The task list presented here is a tool that will help clinics study their workflows so they can plan for changes that will take place because of EHR implementation and/or transformation to a patient centered medical home.
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Affiliation(s)
- Tosha B Wetterneck
- Division of General Internal Medicine, UW School of Medicine and Public Health, 310 North Midvale Blvd., Madison, WI 53705, USA.
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Sittig DF, Ash JS. On the importance of using a multidimensional sociotechnical model to study health information technology. Ann Fam Med 2011; 9:390-1. [PMID: 21911756 PMCID: PMC3185480 DOI: 10.1370/afm.1291] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Dean F. Sittig
- Memorial Hermann Center for Healthcare Quality & Safety, National Center for Cognitive Informatics & Decision Making, School of Biomedical Informatics, University of Texas Health Sciences Center, Houston, Texas
- CORRESPONDING AUTHOR: Dean F. Sittig, PhD, School of Biomedical Informatics, University of Texas Health Sciences Center, 6410 Fannin St, UTPB 1100.43, Houston, TX 77030-3006,
| | - Joan S. Ash
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
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Naik AD, Singh H. Electronic health records to coordinate decision making for complex patients: what can we learn from wiki? Med Decis Making 2011; 30:722-31. [PMID: 21183759 DOI: 10.1177/0272989x10385846] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Processes of communication that guide decision making among clinicians collaboratively caring for complex patients are poorly understood and vary based on local contexts. In this paper, the authors characterize these processes and propose a wiki-style communication model to improve coordination of decision making among clinicians using an integrated electronic health record (EHR). METHODS A narrative review of current patterns of communication among clinicians sharing medical decisions focusing on the emerging and potential roles of EHRs to enhance communication among clinicians caring for complex patients. RESULTS . The authors present the taxonomy of decision making and communication among clinicians caring for complex patients. They then adapt wiki-style communication to propose a novel model of communication among clinicians for decision making within multidisciplinary disease management programs. Future innovations using wiki-style communication among clinicians are also described and placed in the context of medical decisions by clinicians working together in disease management programs. CONCLUSIONS EHR-based wiki-style applications may have the potential to improve communication and care coordination among clinicians caring for complex patients. This could lead to improved quality and safety within multidisciplinary disease management programs.
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Affiliation(s)
- Aanand D Naik
- Health Decision-Making and Communication Program, Houston Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX, USA.
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Hysong SJ, Sawhney MK, Wilson L, Sittig DF, Esquivel A, Singh S, Singh H. Understanding the management of electronic test result notifications in the outpatient setting. BMC Med Inform Decis Mak 2011; 11:22. [PMID: 21486478 PMCID: PMC3100236 DOI: 10.1186/1472-6947-11-22] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 04/12/2011] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Notifying clinicians about abnormal test results through electronic health record (EHR) -based "alert" notifications may not always lead to timely follow-up of patients. We sought to understand barriers, facilitators, and potential interventions for safe and effective management of abnormal test result delivery via electronic alerts. METHODS We conducted a qualitative study consisting of six 6-8 member focus groups (N = 44) at two large, geographically dispersed Veterans Affairs facilities. Participants included full-time primary care providers, and personnel representing diagnostic services (radiology, laboratory) and information technology. We asked participants to discuss barriers, facilitators, and suggestions for improving timely management and follow-up of abnormal test result notifications and encouraged them to consider technological issues, as well as broader, human-factor-related aspects of EHR use such as organizational, personnel, and workflow. RESULTS Providers reported receiving a large number of alerts containing information unrelated to abnormal test results, many of which were believed to be unnecessary. Some providers also reported lacking proficiency in use of certain EHR features that would enable them to manage alerts more efficiently. Suggestions for improvement included improving display and tracking processes for critical alerts in the EHR, redesigning clinical workflow, and streamlining policies and procedures related to test result notification. CONCLUSION Providers perceive several challenges for fail-safe electronic communication and tracking of abnormal test results. A multi-dimensional approach that addresses technology as well as the many non-technological factors we elicited is essential to design interventions to reduce missed test results in EHRs.
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Affiliation(s)
- Sylvia J Hysong
- Houston VA Health Sciences Research & Development Center of Excellence, The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas,
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Karsh BT, Weinger MB, Abbott PA, Wears RL. Health information technology: fallacies and sober realities. J Am Med Inform Assoc 2011; 17:617-23. [PMID: 20962121 DOI: 10.1136/jamia.2010.005637] [Citation(s) in RCA: 195] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Current research suggests that the rate of adoption of health information technology (HIT) is low, and that HIT may not have the touted beneficial effects on quality of care or costs. The twin issues of the failure of HIT adoption and of HIT efficacy stem primarily from a series of fallacies about HIT. We discuss 12 HIT fallacies and their implications for design and implementation. These fallacies must be understood and addressed for HIT to yield better results. Foundational cognitive and human factors engineering research and development are essential to better inform HIT development, deployment, and use.
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Affiliation(s)
- Ben-Tzion Karsh
- Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety, University of Wisconsin, Madison, Wisconsin 53706, USA.
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Sittig DF, Wright A, Meltzer S, Simonaitis L, Evans RS, Nichol WP, Ash JS, Middleton B. Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records. BMC Med Inform Decis Mak 2011; 11:13. [PMID: 21329520 PMCID: PMC3063202 DOI: 10.1186/1472-6947-11-13] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 02/17/2011] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND We have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria. METHODS We developed and fielded a 17-question survey to representatives from nine commercially available EHR vendors and four leading internally developed EHRs. The first part of the survey asked basic questions about the vendor's EHR. The second part asked specifically about the CDS-related system tools and capabilities that each vendor provides. The final section asked about clinical content. RESULTS All of the vendors and institutions have multiple modules capable of providing clinical decision support interventions to clinicians. The majority of the systems were capable of performing almost all of the key knowledge management functions we identified. CONCLUSION If these well-designed commercially-available systems are coupled with the other key socio-technical concepts required for safe and effective EHR implementation and use, and organizations have access to implementable clinical knowledge, we expect that the transformation of the healthcare enterprise that so many have predicted, is achievable using commercially-available, state-of-the-art EHRs.
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Affiliation(s)
- Dean F Sittig
- UTHealth-Memorial Hermann Center for Healthcare Quality & Safety, School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA.
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Bloomrosen M, Starren J, Lorenzi NM, Ash JS, Patel VL, Shortliffe EH. Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting. J Am Med Inform Assoc 2011; 18:82-90. [PMID: 21169620 PMCID: PMC3005876 DOI: 10.1136/jamia.2010.007567] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 11/03/2010] [Indexed: 11/03/2022] Open
Abstract
Federal legislation (Health Information Technology for Economic and Clinical Health (HITECH) Act) has provided funds to support an unprecedented increase in health information technology (HIT) adoption for healthcare provider organizations and professionals throughout the U.S. While recognizing the promise that widespread HIT adoption and meaningful use can bring to efforts to improve the quality, safety, and efficiency of healthcare, the American Medical Informatics Association devoted its 2009 Annual Health Policy Meeting to consideration of unanticipated consequences that could result with the increased implementation of HIT. Conference participants focused on possible unintended and unanticipated, as well as undesirable, consequences of HIT implementation. They employed an input-output model to guide discussion on occurrence of these consequences in four domains: technical, human/cognitive, organizational, and fiscal/policy and regulation. The authors outline the conference's recommendations: (1) an enhanced research agenda to guide study into the causes, manifestations, and mitigation of unintended consequences resulting from HIT implementations; (2) creation of a framework to promote sharing of HIT implementation experiences and the development of best practices that minimize unintended consequences; and (3) recognition of the key role of the Federal Government in providing leadership and oversight in analyzing the effects of HIT-related implementations and policies.
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Magrabi F, Ong MS, Runciman W, Coiera E. An analysis of computer-related patient safety incidents to inform the development of a classification. J Am Med Inform Assoc 2010; 17:663-70. [PMID: 20962128 PMCID: PMC3000751 DOI: 10.1136/jamia.2009.002444] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 09/01/2010] [Accepted: 09/03/2010] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To analyze patient safety incidents associated with computer use to develop the basis for a classification of problems reported by health professionals. DESIGN Incidents submitted to a voluntary incident reporting database across one Australian state were retrieved and a subset (25%) was analyzed to identify 'natural categories' for classification. Two coders independently classified the remaining incidents into one or more categories. Free text descriptions were analyzed to identify contributing factors. Where available medical specialty, time of day and consequences were examined. MEASUREMENTS Descriptive statistics; inter-rater reliability. RESULTS A search of 42,616 incidents from 2003 to 2005 yielded 123 computer related incidents. After removing duplicate and unrelated incidents, 99 incidents describing 117 problems remained. A classification with 32 types of computer use problems was developed. Problems were grouped into information input (31%), transfer (20%), output (20%) and general technical (24%). Overall, 55% of problems were machine related and 45% were attributed to human-computer interaction. Delays in initiating and completing clinical tasks were a major consequence of machine related problems (70%) whereas rework was a major consequence of human-computer interaction problems (78%). While 38% (n=26) of the incidents were reported to have a noticeable consequence but no harm, 34% (n=23) had no noticeable consequence. CONCLUSION Only 0.2% of all incidents reported were computer related. Further work is required to expand our classification using incident reports and other sources of information about healthcare IT problems. Evidence based user interface design must focus on the safe entry and retrieval of clinical information and support users in detecting and correcting errors and malfunctions.
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Affiliation(s)
- Farah Magrabi
- Centre for Health Informatics, University of New South Wales, Sydney, Australia.
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Horsky J, McColgan K, Pang JE, Melnikas AJ, Linder JA, Schnipper JL, Middleton B. Complementary methods of system usability evaluation: Surveys and observations during software design and development cycles. J Biomed Inform 2010; 43:782-90. [DOI: 10.1016/j.jbi.2010.05.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 04/02/2010] [Accepted: 05/17/2010] [Indexed: 10/19/2022]
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Abernethy AP, Etheredge LM, Ganz PA, Wallace P, German RR, Neti C, Bach PB, Murphy SB. Rapid-learning system for cancer care. J Clin Oncol 2010; 28:4268-74. [PMID: 20585094 PMCID: PMC2953977 DOI: 10.1200/jco.2010.28.5478] [Citation(s) in RCA: 284] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 05/17/2010] [Indexed: 11/20/2022] Open
Abstract
Compelling public interest is propelling national efforts to advance the evidence base for cancer treatment and control measures and to transform the way in which evidence is aggregated and applied. Substantial investments in health information technology, comparative effectiveness research, health care quality and value, and personalized medicine support these efforts and have resulted in considerable progress to date. An emerging initiative, and one that integrates these converging approaches to improving health care, is "rapid-learning health care." In this framework, routinely collected real-time clinical data drive the process of scientific discovery, which becomes a natural outgrowth of patient care. To better understand the state of the rapid-learning health care model and its potential implications for oncology, the National Cancer Policy Forum of the Institute of Medicine held a workshop entitled "A Foundation for Evidence-Driven Practice: A Rapid-Learning System for Cancer Care" in October 2009. Participants examined the elements of a rapid-learning system for cancer, including registries and databases, emerging information technology, patient-centered and -driven clinical decision support, patient engagement, culture change, clinical practice guidelines, point-of-care needs in clinical oncology, and federal policy issues and implications. This Special Article reviews the activities of the workshop and sets the stage to move from vision to action.
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Affiliation(s)
- Amy P Abernethy
- Duke Comprehensive Cancer CenteR, Duke University Medical Center, Box 3436, Durham, NC 27710, USA.
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Sittig DF, Classen DC. Safe electronic health record use requires a comprehensive monitoring and evaluation framework. JAMA 2010; 303:450-1. [PMID: 20124542 PMCID: PMC2965782 DOI: 10.1001/jama.2010.61] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Dean F Sittig
- University of Texas at Houston-Memorial Hermann Center for Healthcare Quality and Safety, University of Texas School of Health Information Sciences, 6410 Fannin St, UTPB 1100.43, Houston, TX 77030, USA.
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Singh H, Wilson L, Petersen LA, Sawhney MK, Reis B, Espadas D, Sittig DF. Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication. BMC Med Inform Decis Mak 2009; 9:49. [PMID: 20003236 PMCID: PMC2797509 DOI: 10.1186/1472-6947-9-49] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 12/09/2009] [Indexed: 02/08/2023] Open
Abstract
Background Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response. Methods Using both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention. Results Data from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p < 0.01) and was sustained at month 4 following the intervention. Conclusion Electronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems.
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Affiliation(s)
- Hardeep Singh
- The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, VA Medical Center (152) 2002 Holcombe Blvd, Houston, TX 77030, USA.
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