Electronic health record impact on work burden in small, unaffiliated, community-based primary care practices.

BACKGROUND: The use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices. OBJECTIVE: To study the impact of EHR use on clinician and staff work burden in small, community-based primary care practices. DESIGN: We conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9-14 days over a 4-8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach. PARTICIPANTS: All practice members and selected patients in seven community-based primary care practices in the Northeastern US. KEY RESULTS: The impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHR-related work burden for clinicians, as well as facilitate population-based care. CONCLUSIONS: The complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.

A 4-year intervention to increase adoption of safer dairy farming work practices.

BACKGROUND: Traumatic and musculoskeletal injury rates have been high in dairy farming compared to other industries. Previous work has shown that social marketing efforts can persuade farm managers to adopt practices that reduce injury hazards compared to traditional practices if the new practices maintain profits. METHODS: The intervention disseminated information to 4,300 Northeast Wisconsin dairy farm managers about three safer and more profitable production practices (barn lights, silage bags, and calf feed mixing sites) using information channels that these managers were known to rely on. We evaluated rolling, independent, community-based samples, at baseline and then again after each of four intervention years. We also evaluated samples from Maryland's 1,200 dairy farms after the second through the fourth year of the intervention. Maryland dairy managers read many of the same nationally distributed print mass media that we used in the intervention and so were a "partially exposed" comparison group. RESULTS: The intervention to disseminate information about the innovations was successful. In comparisons before and after the intervention, Wisconsin managers reported getting more information about calf sites from public events and equipment dealers, about silage bags from other farmers and equipment dealers, and about barn lights from public events, other farmers, equipment dealers, consultants, and electrical suppliers. Wisconsin managers also reported getting more information than Maryland managers from public events for barn lights and silage bags. During years three and four, the intervention managed to sustain, but not improve, earlier increases in adoption and awareness from the first 2 years. After adjusting for farm manager and operation variables, intervention years was associated with increased Wisconsin manager adoption of two of three practices in comparisons between the baseline and the fourth intervention year: barn lights (odds ratio = 5.58, 95% confidence interval = 3.39-9.17) and silage bags (OR = 2.94, CI = 1.84-4.70). There were similar results for awareness of barn lights and the calf feeding sites. Compared to Maryland managers, Wisconsin managers reported greater awareness of barn lights. CONCLUSIONS: Disseminating information to managers through information channels that they usually consulted was associated with increased reports of getting information and with greater adoption and awareness of safer, profit-enhancing work practices in a high hazard industry.

That's nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care.

Health information technology (IT) is widely endorsed as a way to improve key health care outcomes, particularly patient safety. Applying a human factors approach, this paper models more explicitly how health IT might improve or worsen outcomes. The human factors model specifies that health IT transforms the work system, which transforms the process of care, which in turn transforms the outcome of care. This study reports on transformations of the medication administration process that resulted from the implementation of one type of IT: bar coded medication administration (BCMA). Registered nurses at two large pediatric hospitals in the US participated in a survey administered before and after one of the hospitals implemented BCMA. Nurses' perceptions of the administration process changed at the hospital that implemented BCMA, whereas perceptions of nurses at the control hospital did not. BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification. The accuracy, usefulness, and consistency of checking patient identification improved as well. In contrast, nurses' perceptions of the usefulness, time efficiency, and ease of the documentation process decreased post-BCMA. Discussion of survey findings is supplemented by observations and interviews at the hospital that implemented BCMA. By considering the way that IT transforms the work system and the work process a practitioner can better predict the kind of outcomes that the IT might produce. More importantly, the practitioner can achieve or prevent outcomes of interest by using design and redesign aimed at controlling work system and process transformations.

Value of human factors to medication and patient safety in the intensive care unit.

Conventional wisdom suggests that the "human factor" in critical care environments is reason for inadequate medication and patient safety. "Human factors" (or human factors engineering) is also a scientific discipline and practice of improving human performance. Using decades of human factors research, this paper evaluates a range of common beliefs about patient safety through a human factors lens. This evaluation demonstrates that human factors provides a framework for understanding safety failures in critical care settings, offers insights into how to improve medication and patient safety, and reminds us that the "human factor" in critical care units is what allows these time-pressured, information-intense, mentally challenging, interruption-laden, and life-or-death environments to function so safely so much of the time.

The technology acceptance model: its past and its future in health care.

Increasing interest in end users' reactions to health information technology (IT) has elevated the importance of theories that predict and explain health IT acceptance and use. This paper reviews the application of one such theory, the Technology Acceptance Model (TAM), to health care. We reviewed 16 data sets analyzed in over 20 studies of clinicians using health IT for patient care. Studies differed greatly in samples and settings, health ITs studied, research models, relationships tested, and construct operationalization. Certain TAM relationships were consistently found to be significant, whereas others were inconsistent. Several key relationships were infrequently assessed. Findings show that TAM predicts a substantial portion of the use or acceptance of health IT, but that the theory may benefit from several additions and modifications. Aside from improved study quality, standardization, and theoretically motivated additions to the model, an important future direction for TAM is to adapt the model specifically to the health care context, using beliefs elicitation methods.

Involving intensive care unit nurses in a proactive risk assessment of the medication management process.

BACKGROUND: Vulnerabilities in the medication manage ment process can lead to serious patient harm. In intensive care units (ICUs), nurses represent the last line of defense against medication errors. Proactive risk assessment (PRA) offers methods for determining how processes can break down and how people involved in such processes can contribute to or recover from a breakdown. Such methods can also be used to identify ICU nurses' contribution to the quality and safety of medication management. METHODS: Observation and interview data of ICU nurses work were used to develop a rich description of the nursing medication management process. A PRA method was conducted in a cardiovascular ICU to identify and evaluate failure modes in the nursing medication management process. The contributing factors to the failure modes and the recovery processes used by nurses were also characterized. RESULTS: A total of 54 failure modes were identified across the seven steps of the medication management process. For the 5 most critical failure modes, nurses listed 21 contributing factors and 21 recovery processes. Ways were identified to redesign the medication management process, one of which consists of dealing with work system factors that contribute to the most critical failure modes. CONCLUSIONS: From a data-analysis viewpoint, this PRA method permits one to address a variety of objectives. Different scoring methods can be used to focus on either frequency or criticality of failure modes; one may also focus on a specific step of the process under study. Efforts in eliminating or mitigating contributing factors would help reduce the criticality of the failure modes in terms of their likelihood and impact on patients and/or nurses. Developing systems to support the recovery processes used by nurses may be another approach to process redesign.

Relationship between number of health problems addressed during a primary care patient visit and clinician workload.

INTRODUCTION: Primary care is complex due to multiple health problems being addressed in each patient visit. Little is known about the effect of the number of problems per encounter (NPPE) on the resulting clinician workload (CWL), as measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). METHODS: We evaluated the relationship between NPPE and CWL across 608 adult patient visits, conducted by 31 clinicians, using hierarchical linear regression. Clinicians were interviewed about outlier visits to identify reasons for higher or lower than expected CWL. RESULTS: Mean NPPE was 3.30 ± 2.0 (sd) and CWL was 47.6 ± 18.4 from a maximum of 100. Mental demand, time demand and effort accounted for 71.5% of CWL. After adjustment for confounders, each additional problem increased CWL by 3.9 points (P < 0.001). Patient, problem, environmental and patient-physician relationship factors were qualitatively identified from interviews as moderators of this effect. CONCLUSION: CWL is positively related to NPPE. Several modifiable factors may enhance or mitigate this effect. Our findings have implications for using a Human Factors (HF) approach to managing CWL.

A systematic review of patient acceptance of consumer health information technology.

A systematic literature review was performed to identify variables promoting consumer health information technology (CHIT) acceptance among patients. The electronic bibliographic databases Web of Science, Business Source Elite, CINAHL, Communication and Mass Media Complete, MEDLINE, PsycArticles, and PsycInfo were searched. A cited reference search of articles meeting the inclusion criteria was also conducted to reduce misses. Fifty-two articles met the selection criteria. Among them, 94 different variables were tested for associations with acceptance. Most of those tested (71%) were patient factors, including sociodemographic characteristics, health- and treatment-related variables, and prior experience or exposure to computer/health technology. Only ten variables were related to human-technology interaction; 16 were organizational factors; and one was related to the environment. In total, 62 (66%) were found to predict acceptance in at least one study. Existing literature focused largely on patient-related factors. No studies examined the impact of social and task factors on acceptance, and few tested the effects of organizational or environmental factors on acceptance. Future research guided by technology acceptance theories should fill those gaps to improve our understanding of patient CHIT acceptance, which in turn could lead to better CHIT design and implementation.

Intervention to increase adoption of safer dairy farming production practices.

OBJECTIVES: We conducted an intervention to increase adoption of three dairy farming practices shown to reduce certain traumatic and musculoskeletal injury hazards. METHODS: The intervention disseminated information to 4,300 Wisconsin dairy farm managers about three safer, more profitable production practices (barn lights, bag silos, and calf feed mixing sites) using information channels upon which these managers were known to rely. We evaluated rolling, independent, community-based samples at baseline and after each of two intervention years. We also evaluated a single sample after the intervention's second year from 1,200 Maryland dairy farm managers who were exposed only to the intervention's nationally distributed print publications, as a "partially exposed" comparison group. RESULTS: In before/after comparisons, Wisconsin managers reported getting more information from print media, public events, and resource people for barn lights and bag silos. Also, Wisconsin managers, in comparison with Maryland managers after the intervention's second year, reported getting more barn lights and bag silo information from public events and resource people, but not from print media. Analyses that adjusted for farm manager, farm operation, and herd variables associated the intervention with increased Wisconsin manager adoption of all three practices after the second intervention year: barn lights (odds ratio [OR] = 2.268, 95% confidence interval [CI] 1.476, 3.485), bag silos (OR = 3.561, 95% CI 2.684, 4.728), and calf feeding sites (OR = 2.433, 95% CI 1.059, 5.591). There were also increases in awareness of barn lights and calf feeding sites. CONCLUSION: Disseminating information to managers through well-known information channels was associated with increased reports of information gathering, adoption, and awareness of safer, profit-enhancing work practices in a high-hazard industry.

Human factors and ergonomics in home care: Current concerns and future considerations for health information technology.

Sicker patients with greater care needs are being discharged to their homes to assume responsibility for their own care with fewer nurses available to aid them. This situation brings with it a host of human factors and ergonomic (HFE) concerns, both for the home care nurse and the home dwelling patient, that can affect quality of care and patient safety. Many of these concerns are related to the critical home care tasks of information access, communication, and patient self-monitoring and self-management. Currently, a variety of health information technologies (HITs) are being promoted as possible solutions to those problems, but those same technologies bring with them a new set of HFE concerns. This paper reviews the HFE considerations for information access, communication, and patients self-monitoring and self-management, discusses how HIT can potentially mitigate current problems, and explains how the design and implementation of HIT itself requires careful HFE attention.

Human factors and systems engineering approach to patient safety for radiotherapy.

The traditional approach to solving patient safety problems in healthcare is to blame the last person to touch the patient. But since the publication of To Err is Human, the call has been instead to use human factors and systems engineering methods and principles to solve patient safety problems. However, an understanding of the human factors and systems engineering is lacking, and confusion remains about what it means to apply their principles. This paper provides a primer on them and their applications to patient safety.

Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.

The authors develop a typology of clinicians' workarounds when using barcoded medication administration (BCMA) systems. Authors then identify the causes and possible consequences of each workaround. The BCMAs usually consist of handheld devices for scanning machine-readable barcodes on patients and medications. They also interface with electronic medication administration records. Ideally, BCMAs help confirm the five "rights" of medication administration: right patient, drug, dose, route, and time. While BCMAs are reported to reduce medication administration errors--the least likely medication error to be intercepted--these claims have not been clearly demonstrated. The authors studied BCMA use at five hospitals by: (1) observing and shadowing nurses using BCMAs at two hospitals, (2) interviewing staff and hospital leaders at five hospitals, (3) participating in BCMA staff meetings, (4) participating in one hospital's failure-mode-and-effects analyses, (5) analyzing BCMA override log data. The authors identified 15 types of workarounds, including, for example, affixing patient identification barcodes to computer carts, scanners, doorjambs, or nurses' belt rings; carrying several patients' prescanned medications on carts. The authors identified 31 types of causes of workarounds, such as unreadable medication barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient identification wristbands (chewed, soaked, missing); nonbarcoded medications; failing batteries; uncertain wireless connectivity; emergencies. The authors found nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted. Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations. Shortcomings in BCMAs' design, implementation, and workflow integration encourage workarounds. Integrating BCMAs within real-world clinical workflows requires attention to in situ use to ensure safety features' correct use.

Modelling the expected net benefits of interventions to reduce the burden of medication errors.

OBJECTIVES: The aim of this study is to estimate the potential costs and benefits of three key interventions (computerized physician order entry [CPOE], additional ward pharmacists and bar coding) to help prioritize research to reduce medication errors. METHODS: A generic model structure was developed to describe the incidence and impacts of medication errors in hospitals. The model follows pathways from medication error points at alternative stages of the medication pathway through to the outcomes of undetected errors. The model was populated from a systematic review of the medication errors literature combined with novel probabilistic calibration methods. Cost ranges were applied to the interventions, the treatment of preventable adverse drug events (pADEs), and the value of the health lost as a result of an ADE. RESULTS: The model predicts annual health service costs of between pound 0.3 million and pound 1 million for the treatment of pADEs in a 400-bed acute hospital in the UK. Including only health service costs, it is uncertain whether any of the three interventions will produce positive net benefits, particularly if high intervention costs are assumed. When the monetary value of lost health is included, all three interventions have a high probability of producing positive net benefits with a mean estimate of around pound 31.5 million for CPOE over a five-year time horizon. CONCLUSIONS: The results identify the potential cost-effectiveness of interventions aimed at medication errors, as well as identifying key drivers of cost-effectiveness that should be specifically addressed in the design of primary evaluations of medication error interventions.

Evaluation of a four year intervention to reduce musculoskeletal hazards among berry growers.

PROBLEM: Fresh market berry production workers are exposed to physical risk factors for musculoskeletal injury. METHOD: We disseminated information through trade publications and other sources to berry managers in seven U.S. states about five prevention through design practices that were both safer and more profitable than traditional methods. We administered mail evaluation questionnaires prior to the intervention and after each of four intervention years to rolling, independent U.S. samples and to comparison New Zealand berry farm manager samples after years one through three. RESULTS: U.S. manager self-reports of reading trade publication information increased compared to baseline values for two of five practices and self-reported awareness increased for four of five practices. There were no increases in adoption. More U.S. than New Zealand managers reported getting information about two practices from trade publications and about four practices from public events. No U.S. versus New Zealand differences were observed in reported awareness or adoption for any practice. IMPACT ON INDUSTRY: This study showed that even a modest campaign can build awareness of safer practices fairly quickly in three to four years among small agricultural firms but that increasing adoption apparently requires more time. Widespread adoption of safer practices could help keep operators in business longer as they age by reducing the workload and musculoskeletal strain associated with labor intensive crop production for them and their workforce. Adoption of practices that also improve profits, like the five practices featured in this study, could also help managers stay in business.

A change management framework for macroergonomic field research.

With the proliferation of macroergonomic field research, it is time to carefully examine how such research should be managed and implemented. We argue that the importance of attending to high-quality implementation of field research is equal to that of methodological rigor. One way to systematically manage the implementation process is to adopt a change management framework, wherein the research project is conceptualized as an instance of organization-level change. Consequently, principles for successful organization-level change from the literature on change management can be used to guide successful field research implementation. This paper briefly reviews that literature, deriving 30 principles of successful change management, covering topics such as political awareness, assembling the change team, generating buy-in, and management support. For each principle, corresponding suggestions for macroergonomic field research practice are presented. We urge other researchers to further develop and adopt frameworks that guide the implementation of field research.

Human factors engineering and patient safety.

The pediatric population has features different from those of adults and that are dynamic during the pediatric age range. Pediatric-specific issues result in potential risks for harm during medical care. Basic and applied human factors research has resulted in improvements in the performance of health adults and those adults who have functional limitations. Future work should focus on systematically understanding the human factors needs of children with the goal of redesigning systems of health care to optimize the safety of children and the performance of their care providers.

Toward a theoretical approach to medical error reporting system research and design.

The release of the Institute of Medicine (Kohn et al., 2000) report "To Err is Human", brought attention to the problem of medical errors, which led to a concerted effort to study and design medical error reporting systems for the purpose of capturing and analyzing error data so that safety interventions could be designed. However, to make real gains in the efficacy of medical error or event reporting systems, it is necessary to begin developing a theory of reporting systems adoption and use and to understand how existing theories may play a role in explaining adoption and use. This paper presents the results of a 9-month study exploring the barriers and facilitators for the design of a statewide medical error reporting system and discusses how several existing theories of technology acceptance, adoption and implementation fit with many of the results. In addition we present an integrated theoretical model of medical error reporting system design and implementation.

The myth of standardized workflow in primary care.

OBJECTIVE: Primary care efficiency and quality are essential for the nation's health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns. METHODS: This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit's progression, and the presence of an electronic health record (EHR) at the clinic. RESULTS: PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit. DISCUSSION: PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a "dance" between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice. CONCLUSIONS: Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP's mental and physical work, resulting in effective, safe, and efficient primary care.

Quality of work life of independent vs employed family physicians in Wisconsin: a WReN study.

PURPOSE: Family physicians in Wisconsin who are mainly employed by large health care organizations have voiced concerns regarding the quality of their work lives. We explored the quality of work life and its relationship to employment by health care organizations. METHODS: We conducted a cross-sectional survey of the 1,482 active members of the Wisconsin Academy of Family Physicians in 2000. RESULTS: A 47% overall response rate was obtained, and 584 respondents could be identified as independent or employed by a health care organization. There were no differences in age or sex between the 2 groups. The independent physicians worked longer hours, were in smaller work groups, and had been in practice longer and in their current practice longer than the employed physicians. Independent physicians reported better working relationships, more satisfaction with family time, more influence over management decisions, better satisfaction with being a physician, better perceived quality of the care they provided, greater ability to achieve professional goals, and lesser intention to leave the practice. CONCLUSIONS: Independent physicians have significantly more positive ratings of several aspects of the quality of their work life compared with physicians employed by health care organizations. Health care organizations need to address these issues if they are to have a satisfied and stable workforce.

Quality management and the work environment: an empirical investigation in a public sector organization.

The integration of quality management initiatives, particularly total quality management (TQM), and ergonomics has received increasing attention from scholars and practitioners. Above all, the question of how TQM programs relate to ergonomic aspects of organizational design and culture is at the center of this discussion. This study examines how elements of a "typical", Deming-inspired, TQM program in the public sector interact with the work environment. Elements of the TQM program were defined and measured using the Malcom Baldridge Award criteria. The specific elements examined were "Management Support of Quality", "Information and Analysis", "Human Resources", "Processes and Quality Results", and "Customer Focus and Satisfaction". The relationship between these TQM elements and the work environment were defined through five separate hypotheses. The work environment was described by the constructs "Supervisor Support", "Task Clarity", "Task Orientation", and "Innovation". Data were obtained through survey questionnaires administered to employees of four departments in a municipal government organization. Results supported three of the hypotheses, but produced some unanticipated outcomes with regard to the other two. Namely, "Management Support of Quality" was significantly related to "Supervisor Support", "Task Orientation", "Task Clarity" and "Innovation"; "Human Resources" was significantly related to "Supervisor Support"; "Processes and Quality Results" was significantly related to "Task Orientation" and "Innovation". Contrary to predicted "Information and Analysis" was negatively related to "Innovation", and "Customer Focus" was unrelated to any of the outcome variables. The relationships between these TQM elements and work environment dimensions are discussed. Implications for TQM and ergonomic practice are analyzed, and directions for future research proposed.