The Impact of Electronic Health Record-Based Simulation During Intern Boot Camp: Interventional Study

Human factors and systems simulation methods to optimize peri-operative EHR design and implementation

The increase in adoption of Electronic Health records (EHR) in healthcare can be overwhelming to users and pose hidden safety threats and inefficiencies if the system is not well aligned with workflows. This quality improvement study, facilitated from September 2023-April 2024, aimed to proactively test a new EHR using systems focused simulation and Human factors methods, prior to go-live, in a peri-operative children's hospital setting to improve safety, efficiency and usability of the EHR. The project was conducted at a large, academic, quaternary care children's hospital undergoing a transition from one EHR to another. Two cycles of usability testing followed by in situ simulations focused on testing the new EHR with interprofessional peri-operative team members prior to go live. Usability testing, using relevant clinical workflows, was completed over zoom using the EHR "testing" environment with individual care providers across multiple peri-operative roles. In situ simulations were facilitated in the actual peri-operative and Otolaryngology clinic spaces with full interprofessional teams. Qualitative data was collected and summarized through debriefing and recordings of the sessions. Human factors and patient safety principles were integrated throughout the recommendations. A total of 475 recommendations were made to improve the safety, efficiency, usability, and optimization of the EHR. The outcomes included a range of usability and system issues including latent safety threats and their impact on safe and quality patient care. There was a plethora of usability improvements, including some critical issues that were uncovered and mitigated prior to the go live date.

Centralized Multipatient Dashboards' Impact on Intensive Care Unit Clinician Performance and Satisfaction: A Systematic Review

BACKGROUND

 Intensive care unit (ICU) clinicians encounter frequent challenges with managing vast amounts of fragmented data while caring for multiple critically ill patients simultaneously. This may lead to increased provider cognitive load that may jeopardize patient safety.

OBJECTIVES

 This systematic review assesses the impact of centralized multipatient dashboards on ICU clinician performance, perceptions regarding the use of these tools, and patient outcomes.

METHODS

 A literature search was conducted on February 9, 2023, using the EBSCO CINAHL, Cochrane Central Register of Controlled Trials, Embase, IEEE Xplore, MEDLINE, Scopus, and Web of Science Core Collection databases. Eligible studies that included ICU clinicians as participants and tested the effect of dashboards designed for use by multiple users to manage multiple patients on user performance and/or satisfaction compared with the standard practice. We narratively synthesized eligible studies following the SWiM (Synthesis Without Meta-analysis) guidelines. Studies were grouped based on dashboard type and outcomes assessed.

RESULTS

 The search yielded a total of 2,407 studies. Five studies met inclusion criteria and were included. Among these, three studies evaluated interactive displays in the ICU, one study assessed two dashboards in the pediatric ICU (PICU), and one study examined centralized monitor in the PICU. Most studies reported several positive outcomes, including reductions in data gathering time before rounds, a decrease in misrepresentations during multidisciplinary rounds, improved daily documentation compliance, faster decision-making, and user satisfaction. One study did not report any significant association.

CONCLUSION

 The multipatient dashboards were associated with improved ICU clinician performance and were positively perceived in most of the included studies. The risk of bias was high, and the certainty of evidence was very low, due to inconsistencies, imprecision, indirectness in the outcome measure, and methodological limitations. Designing and evaluating multipatient tools using robust research methodologies is an important focus for future research.

Management of the Electronic Health Record Inbox: Results From a National Survey of Internal Medicine Program Directors

Background Internal medicine (IM) resident physicians spend a considerable amount of time managing their inbox as part of their longitudinal continuity clinic experience. There are no standardized guidelines for how programs should train, monitor, or supervise residents in this type of patient care. Objective To understand how IM residency programs educate, monitor, and supervise resident electronic health record (EHR) inbox management as part of their longitudinal continuity clinic and determine whether patient safety events have occurred due to EHR inbox-related patient care decisions made by unsupervised resident physicians. Methods In August 2021, 439 program directors at accredited US IM residency programs who were members of the Association of Program Directors in Internal Medicine (APDIM) were asked 12 questions developed by the study authors and APDIM survey committee members regarding resident EHR inbox management as part of the annual APDIM survey. Results Two hundred and sixty-seven (61%) PDs responded. The majority (224 of 267, 84%) of programs provided guidelines for expected message response times; less than half (115, 43%) monitored timeliness metrics. Only half (135; 51%) of programs required faculty supervision of inbox messages for all residents; 28% (76) did not require supervision for any residents. Twenty-one percent of PDs (56) reported awareness of a patient safety event occurring due to an unsupervised resident inbox-related patient care decision. Conclusions Substantial variability exists in how IM residency programs train, monitor, supervise, and provide coverage for resident inbox work. Program directors are aware of patient safety events resulting from unsupervised resident inbox management.

Effect of Tailored Coaching on Physicians' Electronic Health Record Proficiency and User Experience: A Randomized Crossover Study

Objective

To examine the effect of a tailored EHR coaching intervention, informed by audit log data, on physicians' EHR proficiency, and user experience among pediatricians.

Patients and Methods

A 12-month (August 2020 - August 2021) randomized crossover quality improvement study of a tailored EHR coaching was conducted on 34 pediatric physicians at a major medical center. Participants were randomized into Group AB or Group BA. The intervention was a single 1-hour, one-on-one coaching session. An Epic certified pediatrician tailored each coaching session to meet each physician needs using their EHR audit log data. We analyzed EHR audit log data for 3 months pre- and post-intervention.

Results

Out of the 34 physicians, 15 (44%) were primary care pediatricians, 19 (56%) were female, 24 (70%) practiced at the medical center. During the initial intervention, the average proficiency score for the Group AB increased by 8.9% (pre-post difference: 0.37, 95% CI: -0.35 to 1.09; P-value=.381). For the crossover intervention, the average proficiency score for Group BA significantly increased by 11.2% (pre-post difference: 0.31, 95% CI: -0.11 to 0.74; P-value=.05). The average perceived EHR workload decreased post coaching sessions compared to pre-session (50.89 vs 46.66, P-value=.06). Post-coaching intervention, the average score for perceived EHR usability improved compared to pre-intervention (4.10 vs 4.34; P-value=.1).

Conclusion

Electronic health record audit log data can be used to inform tailored coaching to improve physicians' EHR proficiency levels and user experience. Tailored EHR coaching can increase awareness about efficiency tools available in the EHR. These findings are relevant to decisionmakers and learning health systems interested in provider well-being by optimizing EHR use.

Development of integrated electronic medical and dental record competencies and impact of training modalities

BACKGROUND

The American Recovery and Reinvestment Act provided incentives for the adoption of electronic health records. The integrated electronic medical and dental records (iEMDRs) can minimize healthcare charting errors. The use of iEMDR by healthcare students requires training and competence. There are no defined student competencies to assess the effective and responsible use of iEMDR in dentistry. The goal of this study was to propose a student competency model and study the impact of training modalities on iEMDR competency.

METHODS

This retrospective observational cohort study evaluated de-identified assessment scores (AS) and performance scores (PS) in predoctoral dental student (PDS) and advanced standing predoctoral (ASP) student cohorts that received remote or in-person iEMDR training. The AS and PS evaluated the knowledge and application of iEMDR, respectively. A voluntary survey evaluated students' self-perceived preparedness for iEMDR use. Linear regressions were used to determine the association between training modality and scores. Mantel-Haenszel ordinal chi-square tested differences between groups and agreement by training type. Statistical significance was set at 0.05.

RESULTS

The sample size (N = 214) provided 95% power to detect differences between study groups. The knowledge of iEMDR (AS) was not impacted due to the training type (p = 0.90) in either student cohorts, whereas the application of knowledge (PS) was higher in ASP student cohort after remote training (p < 0.001) as compared to PDS student cohort. Higher proportion of students perceived preparedness after remote learning in comparison to in-person training (p < 0.001).

DISCUSSION

The iEMDR competency model was useful to test the effective and responsible use of iEMDR, and remote training improved students' self-perceived preparedness.

Just-in-Time Electronic Health Record Retraining to Support Clinician Redeployment during the COVID-19 Surge

BACKGROUND

In response to surges in demand for intensive care unit (ICU) care related to the COVID-19 pandemic, health care systems have had to increase hospital capacity. One institution redeployed certified registered nurse anesthetists (CRNAs) as ICU clinicians, which necessitated training in ICU-specific electronic health record (EHR) workflows prior to redeployment. Under time- and resource-constrained settings, clinical informatics (CI) fellows could effectively be lead instructors for such training.

OBJECTIVE

This study aimed to deploy CI fellows as lead EHR instructional trainers for clinician redeployment as part of an organization's response to disaster management.

METHODS

CI fellows led a multidisciplinary team alongside subject matter experts to develop and deploy a tailored EHR curriculum comprising in-person classes and online video modules, leveraging high-fidelity simulated patient cases. The participants completed surveys immediately after the in-person training session and after deployment.

RESULTS

Eighteen CRNAs participated, with 15 completing the postactivity survey (83%). All felt the training was useful and improved their EHR skills with a Net Promoter score of +87. Most (93%) respondents indicated the pace of the session was "just right," and 100% felt the clarity of instruction was "just right" or "extremely easy" to understand. Twelve participants (67%) completed the postdeployment survey. The training increased comfort in the ICU for all respondents, and 91% felt the training prepared them to work in the ICU with minimal guidance. All stated that the concepts learned would be useful in their anesthesia role. Fifty-eight percent viewed the online video library.

CONCLUSION

This case report demonstrates that CI fellows with dual domain expertise in their clinical specialty and informatics are uniquely poised to deliver clinician redeployment EHR training in response to operational crises. Such opportunities can achieve fellowship educational goals while conserving physician resources which can be a strategic option as organizations plan for disaster management.

Temporal Associations Between EHR-Derived Workload, Burnout, and Errors: a Prospective Cohort Study

BACKGROUND

The temporal progression and workload-related causal contributors to physician burnout are not well-understood.

OBJECTIVE

To characterize burnout's time course and evaluate the effect of time-varying workload on burnout and medical errors.

DESIGN

Six-month longitudinal cohort study with measurements of burnout, workload, and wrong-patient orders every 4 weeks.

PARTICIPANTS

Seventy-five intern physicians in internal medicine, pediatrics, and anesthesiology at a large academic medical center.

MAIN MEASURES

Burnout was measured using the Professional Fulfillment Index survey. Workload was collected from electronic health record (EHR) audit logs and summarized as follows: total time spent on the EHR, after-hours EHR time, patient load, inbox time, chart review time, note-writing time, and number of orders. Wrong-patient orders were assessed using retract-and-reorder events.

KEY RESULTS

Seventy-five of 104 interns enrolled (72.1%) in the study. A total of 337 surveys and 8,863,318 EHR-based actions were analyzed. Median burnout score across the cohort across all time points was 1.2 (IQR 0.7-1.7). Individual-level burnout was variable (median monthly change 0.3, IQR 0.1-0.6). In multivariable analysis, increased total EHR time (β=0.121 for an increase from 54.5 h per month (25th percentile) to 123.0 h per month (75th percentile), 95%CI=0.016-0.226), increased patient load (β=0.130 for an increase from 4.9 (25th percentile) to 7.1 (75th percentile) patients per day, 95%CI=0.053-0.207), and increased chart review time (β=0.096 for an increase from 0.39 (25th percentile) to 0.59 (75th percentile) hours per patient per day, 95%CI=0.015-0.177) were associated with an increased burnout score. After adjusting for the total number of ordering sessions, burnout was not statistically associated with an increased rate of wrong-patient orders (rate ratio=1.20, 95%CI=0.76-1.89).

CONCLUSIONS

Burnout and recovery were associated with recent clinical workload for a cohort of physician trainees, highlighting the elastic nature of burnout. Wellness interventions should focus on strategies to mitigate sustained elevations of work responsibilities.

Translating ethnographic data into knowledge, skills, and attitude statements for medical scribes: a modified Delphi approach

OBJECTIVE

While the use of medical scribes is rapidly increasing, there are not widely accepted standards for their training and duties. Because they use electronic health record systems to support providers, inadequately trained scribes can increase patient safety related risks. This paper describes the development of desired core knowledge, skills, and attitudes (KSAs) for scribes that provide the curricular framework for standardized scribe training.

MATERIALS AND METHODS

A research team used a sequential mixed qualitative methods approach. First, a rapid ethnographic study of scribe activities was performed at 5 varied health care organizations in the United States to gather qualitative data about knowledge, skills, and attitudes. The team's analysis generated preliminary KSA related themes, which were further refined during a consensus conference of subject-matter experts. This was followed by a modified Delphi study to finalize the KSA lists.

RESULTS

The team identified 90 descriptions of scribe-related KSAs and subsequently refined, categorized, and prioritized them for training development purposes. Three lists were ultimately defined as: (1) Hands-On Learning KSA list with 47 items amenable to simulation training, (2) Didactic KSA list consisting of 32 items appropriate for didactic lecture teaching, and (3) Prerequisite KSA list consisting of 11 items centered around items scribes should learn prior to being hired or soon after being hired.

CONCLUSION

We utilized a sequential mixed qualitative methodology to successfully develop lists of core medical scribe KSAs, which can be incorporated into scribe training programs.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Using A New Model of Electronic Health Record Training To Reduce Physician Burnout: A Plan For Action

UNSTRUCTURED

Physician burnout has been growing in the US at an alarming rate, and healthcare organizations are beginning to invest significant resources in combating this phenomenon. While the causes for burnout are multifactorial, a key issue that affects physicians is that they spend a significant proportion of their time interacting with their electronic health record (EHR), primarily because of the need to sift through increasing amounts of patient data coupled with a significant documentation burden. This has led to physicians spending increasing amounts time with the EHR after hours trying to catch up on paperwork ("pajama time"), which is a factor linked to burnout. In this paper we propose an innovative model of EHR training utilizing high-fidelity EHR simulation designed to facilitate efficient optimization of EHR use by clinicians, and emphasize the importance of both lifelong learning and physician well-being.