A qualitative study of the dark and bright sides of physicians' electronic health record work outside work hours.

BACKGROUND: The introduction of electronic health records (EHRs) has contributed considerably to EHR work outside work (WOW) hours for physicians. Prior research has identified the pressures associated with stress resulting from EHR WOW, yet developing a nuanced understanding of how physicians appraise and respond to this stress, and the resulting impacts, remains absent from the literature. PURPOSE: Grounded in the technostress model, this study takes a qualitative approach to explore both the pressures and opportunities associated with EHR WOW. METHODS: Thematic analysis of data from semistructured interviews was utilized to examine the pressures and opportunities associated with EHR WOW among primary care pediatricians (n = 15) affiliated with a large Midwestern pediatric health system. RESULTS: The physicians in this study regularly spent time working in the EHR outside work hours. They felt the EHR contributed to their documentation burden, which ultimately increased their EHR WOW, and reported a sense of burden from ubiquitous EHR availability. Conversely, they appreciated the flexibility the EHR provided in terms of work-life balance. Suggestions for improvement under the direct purview of practice management included enhanced EHR usability, improvements in workflow during work hours to free up time to document, and more training on both EHR documentation strategies and ongoing software upgrades. CONCLUSION: Physicians perceive that the EHR exerts certain pressures while affording new opportunities and conveniences. This study provides evidence of both the pressures and opportunities of EHR WOW and their effect on physician well-being. PRACTICE IMPLICATIONS: Specific opportunities are identified for health administrators to enable physicians to better manage EHR WOW.

A Comparison of Benefit Limits in Mental Health.

This study provides insight to policy makers and stakeholders on how three types of benefits limits on Medicaid-covered mental health services might affect access for consumers diagnosed with severe mental illness. The study used a retrospective cohort design with data for Medicaid-covered, community-based mental health services provided in Ohio during fiscal year 2010. Log-binomial regression was used for the analysis. Results indicate that limits compared have significant, varying consequences based on Medicaid coverage and diagnoses. When constraining Medicaid costs, policy makers should consider how limits will disrupt care and include clinicians in discussions prior to implementation.

Performance of experienced versus less experienced paramedics in managing challenging scenarios: a cognitive task analysis study.

STUDY OBJECTIVE: Out-of-hospital care is becoming more complex, thus placing greater reliance on the cognitive abilities of paramedics to manage difficult situations. In adapting to the challenges in their work, paramedics develop expertise. We study the cognitive strategies used by expert paramedics to contribute to understanding how paramedics and the EMS system can adapt to new challenges. METHODS: We conducted a "staged-world" cognitive task analysis to explore paramedics' handling of cognitive challenges related to sense-making and to resource and task management. A mixed-fidelity simulation was used to present paramedics with 2 challenging scenarios: a pulmonary embolism initially presenting as a myocardial infarction and a 2-person shooting with limited resources available. RESULTS: Participants were 10 paramedics, 6 more experienced and 4 less experienced. Analysis involved comparing the performance of the 2 groups to identify strategies associated with expertise. The more experienced paramedics made more assessments, explored a wider variety of presumptive diagnoses, and identified the pulmonary embolism earlier. They switched attention between the 2 shooting victims more, used their emergency medical technician-basic level partners more, and provided more advanced level care for both patients. Their patients arrived at the emergency department more prepared for specialized emergency care. CONCLUSION: Our findings correspond to general cognitive attributes of expertise: greater cue gathering and inferential reasoning, and more functional and strategic thinking. These results suggest potential areas and methods to facilitate development of expertise, as well as ways to better support use of expertise. Future studies should expand on these findings through larger sample sizes and more complex scenarios.

Characterization of Electronic Health Record Use Outside Scheduled Clinic Hours Among Primary Care Pediatricians: Retrospective Descriptive Task Analysis of Electronic Health Record Access Log Data.

BACKGROUND: Many of the benefits of electronic health records (EHRs) have not been achieved at expected levels because of a variety of unintended negative consequences such as documentation burden. Previous studies have characterized EHR use during and outside work hours, with many reporting that physicians spend considerable time on documentation-related tasks. These studies characterized EHR use during and outside work hours using clock time versus actual physician clinic schedules to define the outside work time. OBJECTIVE: This study aimed to characterize EHR work outside scheduled clinic hours among primary care pediatricians using a retrospective descriptive task analysis of EHR access log data and actual physician clinic schedules to define work time. METHODS: We conducted a retrospective, exploratory, descriptive task analysis of EHR access log data from primary care pediatricians in September 2019 at a large Midwestern pediatric health center to quantify and identify actions completed outside scheduled clinic hours. Mixed-effects statistical modeling was used to investigate the effects of age, sex, clinical full-time equivalent status, and EHR work during scheduled clinic hours on the use of EHRs outside scheduled clinic hours. RESULTS: Primary care pediatricians (n=56) in this study generated 1,523,872 access log data points (across 1069 physician workdays) and spent an average of 4.4 (SD 2.0) hours and 0.8 (SD 0.8) hours per physician per workday engaged in EHRs during and outside scheduled clinic hours, respectively. Approximately three-quarters of the time working in EHR during or outside scheduled clinic hours was spent reviewing data and reports. Mixed-effects regression revealed no associations of age, sex, or clinical full-time equivalent status with EHR use during or outside scheduled clinic hours. CONCLUSIONS: For every hour primary care pediatricians spent engaged with the EHR during scheduled clinic hours, they spent approximately 10 minutes interacting with the EHR outside scheduled clinic hours. Most of their time (during and outside scheduled clinic hours) was spent reviewing data, records, and other information in EHR.

Registered nurses' judgments of the classification and risk level of patient care errors.

As frontline clinicians, nurses play a critical role in mitigating patient harm, recovery from health care errors, and overall improvement of patient safety. This cross-sectional study asked nurse respondents to make judgments about the classification and severity of errors in 4 clinical vignettes. Our results showed that agreement about error classification and associated risk among registered nurses is less than optimal. Further research is needed to advance our understanding of how nurses working in complex patient care situations can improve their ability to recognize subtle cues to facilitate early recognition of potential errors.

Factors Associated With Electronic Health Record Usage Among Primary Care Physicians After Hours: Retrospective Cohort Study.

BACKGROUND: There is limited published data on variation in physician usage of electronic health records (EHRs), particularly after hours. Research in this area could provide insight into the effects of EHR-related workload on physicians. OBJECTIVE: This study sought to examine factors associated with after-hours EHR usage among primary care physicians. METHODS: Electronic health records usage information was collected from primary care pediatricians in a large United States hospital. Inclusion criteria consisted solely of being a primary care physician who started employment with the hospital before the study period, so all eligible primary care physicians were included without sampling. Mixed effects statistical modeling was used to investigate the effects of age, gender, workload, normal-hour usage, week to week variation, and provider-to-provider variation on the after-hour usage of EHRs. RESULTS: There were a total of 3498 weekly records obtained on 50 physicians, of whom 22% were male and 78% were female. Overall, more EHR usage during normal work hours was associated with decreased usage after hours. The more work relative value units generated by physicians, the more time they spent interacting with EHRs after hours (ß=.04, P<.001) and overall (ie, during normal hours and after hours) (ß=.24, P<.001). Gender was associated with total usage time, with females spending more time than males (P=.03). However, this association was not observed with after-hours EHR usage. provider-to-provider variation was the largest and most dominant source of variation in after-hour EHR usage, which accounted for 52% of variance of total EHR usage. CONCLUSION: The present study found that there is a considerable amount of variability in EHR use among primary care physicians, which suggested that many factors influence after-hours EHR usage by physicians. However, provider-to-provider variation was the largest and most dominant source of variation in after-hours EHR usage. While the results are intuitive, future studies should consider the effect of EHR use variations on workload efficiency.

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors.

PURPOSE: In order to better understand physicians' perspectives about the use of clinical information technology (CIT) to reduce medical errors, we asked physicians about opportunities and issues around clinical use of computerized physician order entry (CPOE) systems, order sets within CPOE, and handheld computers (HHCs). METHODS: We conducted 10 focus groups including 71 physicians involved in technology implementation efforts across the US between April 2002 and February 2005. RESULTS: Two major themes emerged across focus groups around reliance on CIT to reduce errors: (1) can it work? and (2) at what cost to the medical profession? Within the first theme, physicians expressed concern about the appropriateness of physician-directed CIT as a solution for medical errors, concerns regarding the current technical capabilities and level of technical support for CIT solutions, and concern about the introduction of new errors. Within the second theme, physicians were particularly concerned about time efficiency and workload redistribution associated with the introduction of CIT. Across focus groups, physicians tended to generalize about the role of all IT in their lives, potentially biasing opinions about specific technologies. CONCLUSIONS: Health care organizations attempting to promote physician use of CIT are advised to deepen consideration of physicians' perspectives about technology adoption and use in order to address their concerns, reduce skepticism, and increase the likelihood of implementation success.

Organizational and physician perspectives about facilitating handheld computer use in clinical practice: results of a cross-site qualitative study.

OBJECTIVE: To describe strategies that organizations select to support physicians' use of handheld computers (HHCs) in clinical practice and to explore issues about facilitating HHC use. DESIGN: A multidisciplinary team used focus groups and interviews with clinical, administrative, and information technology (IT) staff to gather data from 161 informants at seven sites. Transcripts were coded using a combination of deductive and inductive approaches to both answer research questions and identify patterns and themes that emerged in the data. MEASUREMENTS: Answers to questions about strategies for HHC support and themes about (1) how to facilitate physician adoption and use and (2) organizational concerns. RESULTS: Three main organizational strategies for HHC support were characterized among sites: (1) active support for broad-based use, (2) active support for niche use, and (3) basic support for individual physician users. Three high-level themes emerged around how to best facilitate physician adoption and use of HHCs: (1) improving usability and usefulness, (2) promoting HHCs and device use, and (3) providing training and support. However, four major themes also emerged related to organizations' concerns about HHC use: (1) security-related concerns, (2) economic concerns, (3) technical concerns, and (4) strategic concerns. CONCLUSION: An organizational approach to HHC support that involves individualized attention to existing and potential physician users rather than one-size-fits-all, organization-wide implementation efforts was an important facilitator promoting physician use of HHCs. Health care organizations interested in supporting HHC use must consider issues related to security, economics, and IT strategy that may not be prominent concerns for physician users.

Guideline attribute and implementation preferences among physicians in multiple health systems.

OBJECTIVES: Although practice guidelines are effective in assisting providers with clinical decision making, ineffective implementation strategies often prevent their use in practice. This study aimed to understand physician preferences for guideline format, placement, content, evidence, and learning strategies in different clinical environments. SUBJECTS AND METHODS: Semistructured telephone interviews were conducted with 500 randomly selected physicians from 4 major US health systems who were involved in the treatment of patients with acute myocardial infarction or pediatric asthma. Paired sample t tests and Tukey's method of comparisons determined the relative ranking of physicians' guideline implementation preferences. RESULTS: Physicians preferred guidelines located on the front of the patient chart, in palm pilots, or in progress notes and presented as flow charts/flow diagrams, algorithms, or preprinted orders that contain strategies to minimize readmits/encourage self-management and immediate treatment flows. Discussions with colleagues and continuing medical education are the most effective strategies for encouraging guideline use, and randomized controlled trials remain the most persuasive medical evidence. CONCLUSIONS: Health care organizations must align guideline implementation efforts with physician preferences to encourage utilization. The results of this study reveal systematic physician preferences for guideline implementation that can be applied to clinical settings to encourage guideline use by physicians.

Perceived barriers to medical-error reporting: an exploratory investigation.

Medical-error reporting is an essential component for patient safety enhancement. Unfortunately, medical errors are largely underreported across healthcare institutions. This problem can be attributed to different factors and barriers present at organizational and individual levels that ultimately prevent individuals from generating the report. This study explored the factors that affect medical-error reporting among physicians and nurses at a large academic medical center located in the midwest United States. A nominal group session was conducted to identify the most relevant factors that act as barriers for error reporting. These factors were then used to design a questionnaire that explored the likelihood of the factors to act as barriers and their likelihood to be modified. Using these two parameters, the results were analyzed and combined into a Factor Relevance Matrix. The matrix identifies the factors for which immediate actions should be undertaken to improve medical-error reporting (immediate action factors). It also identifies factors that require long-term strategies (long-term strategy factors) as well as factors that the organization should be aware of but that are of lower priority (awareness factors). The strategies outlined in this study may assist healthcare organizations in improving medical-error reporting, as part of the efforts toward patient-safety enhancement. Although factors affecting medical-error reporting may vary between different organizations, the process used in identifying the factors and the Factor Relevance Matrix developed in this study are easily adaptable to any organizational setting.

The applicability of Lean and Six Sigma techniques to clinical and translational research.

BACKGROUND: Lean and Six Sigma are business management strategies commonly used in production industries to improve process efficiency and quality. During the past decade, these process improvement techniques increasingly have been applied outside the manufacturing sector, for example, in health care and in software development. This article concerns the potential use of Lean and Six Sigma in improving the processes involved in clinical and translational research. Improving quality, avoiding delays and errors, and speeding up the time to implementation of biomedical discoveries are prime objectives of the National Institutes of Health (NIH) Roadmap for Medical Research and the NIH's Clinical and Translational Science Award program. METHODS: This article presents a description of the main principles, practices, and methods used in Lean and Six Sigma. Available literature involving applications of Lean and Six Sigma to health care, laboratory science, and clinical and translational research is reviewed. Specific issues concerning the use of these techniques in different phases of translational research are identified. RESULTS: Examples of Lean and Six Sigma applications that are being planned at a current Clinical and Translational Science Award site are provided, which could potentially be replicated elsewhere. We describe how different process improvement approaches are best adapted for particular translational research phases. CONCLUSIONS: Lean and Six Sigma process improvement methods are well suited to help achieve NIH's goal of making clinical and translational research more efficient and cost-effective, enhancing the quality of the research, and facilitating the successful adoption of biomedical research findings into practice.

Empirical support for the Baldrige Award framework in U.S. hospitals.

Examined are relationships among constructs in the Baldrige Award Health Care Criteria framework to investigate whether quality management systems are related to organizational results and customer satisfaction in hospitals. Measures for the 19 dimensions of the Baldrige Criteria are obtained from 220 U.S. hospitals. This study provides empirical evidence that focusing on the content addressed in the Baldrige Criteria leads hospitals to improvement on some dimensions of performance.

Doctors' experience with handheld computers in clinical practice: qualitative study.

OBJECTIVE: To examine doctors' perspectives about their experiences with handheld computers in clinical practice. DESIGN: Qualitative study of eight focus groups consisting of doctors with diverse training and practice patterns. SETTING: Six practice settings across the United States and two additional focus group sessions held at a national meeting of general internists. PARTICIPANTS: 54 doctors who did or did not use handheld computers. RESULTS: Doctors who used handheld computers in clinical practice seemed generally satisfied with them and reported diverse patterns of use. Users perceived that the devices helped them increase productivity and improve patient care. Barriers to use concerned the device itself and personal and perceptual constraints, with perceptual factors such as comfort with technology, preference for paper, and the impression that the devices are not easy to use somewhat difficult to overcome. Participants suggested that organisations can help promote handheld computers by providing advice on purchase, usage, training, and user support. Participants expressed concern about reliability and security of the device but were particularly concerned about dependency on the device and over-reliance as a substitute for clinical thinking. CONCLUSIONS: Doctors expect handheld computers to become more useful, and most seem interested in leveraging (getting the most value from) their use. Key opportunities with handheld computers included their use as a stepping stone to build doctors' comfort with other information technology and ehealth initiatives and providing point of care support that helps improve patient care.