A qualitative evaluation of the crucial attributes of contextual information necessary in EHR design to support patient-centered medical home care.

BACKGROUND: Effective implementation of a Primary Care Medical Home model of care (PCMH) requires integration of patients' contextual information (physical, mental, social and financial status) into an easily retrievable information source for the healthcare team and clinical decision-making. This project explored clinicians' perceptions about important attributes of contextual information for clinical decision-making, how contextual information is expressed in CPRS clinical documentation as well as how clinicians in a highly computerized environment manage information flow related to these areas. METHODS: A qualitative design using Cognitive Task Analyses and a modified Critical Incident Technique were used. The study was conducted in a large VA with a fully implemented EHR located in the western United States. Seventeen providers working in a PCMH model of care in Primary Care, Home Based Care and Geriatrics reported on a recent difficult transition requiring contextual information for decision-making. The transcribed interviews were qualitatively analyzed for thematic development related to contextual information using an iterative process and multiple reviewers with ATLAS@ti software. RESULTS: Six overarching themes emerged as attributes of contextual information: Informativeness, goal language, temporality, source attribution, retrieval effort, and information quality. CONCLUSIONS: These results indicate that specific attributes are needed to in order for contextual information to fully support clinical decision-making in a Medical Home care delivery environment. Improved EHR designs are needed for ease of contextual information access, displaying linkages across time and settings, and explicit linkages to both clinician and patient goals. Implications relevant to providers' information needs, team functioning and EHR design are discussed.

Veterans Healthcare Administration providers' attitudes and perceptions regarding pragmatic trials embedded at the point of care.

Background The Veterans Healthcare Administration (VA) is implementing an adaptation of a pragmatic trial program, Point of Care Research (POC-R). The goal of POC-R is to embed research into clinical practice, contributing to a Learning Healthcare System. Provider acceptance and participation in POC-R is essential to its successful implementation. The purpose of this study is to evaluate provider's perceptions and beliefs regarding the POC-R program. Methods Provider focus groups and interviews were conducted at seven VA medical facilities involving 62 providers. A semi-structured script was used that included descriptions of four use cases and targeted questions regarding perceptions, concerns, and attitudes about the POC-R program. Sessions were audio-taped, de-identified, transcribed, and analyzed using systematic qualitative techniques to create response categories and overarching themes. Results The emergent themes were as follows: (1) POC-R is a valuable component of evidence-based practice, providing an opportunity to base clinical practice on more generalizable evidence as well as providing tools to improve local practice; (2) POC-R highlights the tension between the need for autonomy of practice and compliance with protocols; (3) POC-R may create increased time and burden resulting from added research responsibilities; (4) concern about the scientific validity and reliability of results; (5) potential for a negative impact on the provider-patient relationship; and (6) uncertainty regarding what constitutes equipoise, given differences in provider knowledge and preferences. Despite substantive concerns, barriers were generally felt to be solvable. Implementation should include provider education, careful attention to workflow for all arms of the study, inclusion of the entire team, and adequate oversight. Limitations The study design is qualitative with limited implications for causal inference. Participants are from the VA and may not be representative of other clinicians. Conclusion VA providers are supportive of the importance and value of pragmatic trials in general and of POC-R in particular. However, providers have significant concerns regarding the burden, ethics, and evidence regarding equipoise. Results are discussed in terms of implementation recommendations.

Comparing narrative versus numerical display of functional information: impact on sense-making.

Contextual information consists of functional, social, and financial information about patients. Physicians routinely have difficulty incorporating contextual information into clinical decision-making despite the emphasis on patient-centered care and functional status. One reason for this difficulty is that such information is not well-represented in the patient medical record. This study assesses the impact of a "story-form" model versus a "medical" model on a practitioner's ability to recall and incorporate contextual information. We assessed this question through the analysis of responses of 30 clinicians to 2 vignettes presenting contextual information in both formats. Overall, there was a statistically significant difference between the narrative and numerical form with those receiving the narrative form for contextual information being more likely to consider it a top issue. Reference to goals in the report of key clinical factors was also significantly higher for the group receiving goal information. Implications for sharing contextual information in EMRs are discussed.

Support for contextual control in primary care: a qualitative analysis.

Providing support for high-level cognitive performance is largely missing in many decision support designs. Most development in this area is structured to minimize attention, decrease the need for deeper processing and limit intense goal-directed cognitive processing. However, from a dual process perspective, both automatic and deliberative processes need to be supported. The purpose of this qualitative analysis is to explore complex cognitive processing. We used the Contextual Control Model to guide the analysis. Transcripts from 33 taped primary care visits across 4 locations in the VA were analyzed using iterative process of construct and thematic development. Five themes related to high-level cognitive processes were identified: 1) Joint Exchange and Patient Activation; 2) Planning and Proactive Problem Solving; 3) Script and heuristic processing; 4) Time perspectives and 5) Uncertainty management. Results are discussed in terms of the need to support integrated views for complex situation mental models.

The relationship between structural characteristics of 2010 challenge documents and ratings of document quality.

Quality of clinical narratives has direct impact on the perceived usefulness of these documents. With the advent of electronic documentation, the quality of clinical documents has been debated. Electronic documentation is supported by features to enhance efficiency, including copy/paste, templates, multi-level headings, and inserted objects. The impact of these features on perceived document quality has been difficult to assess in real settings as compared to simulations. This study used electronic notes from the 2010 i2b2/VA Challenge to explore the impact of text characteristics on general perception of document quality. We administered a validated instrument to assess document quality, focusing on two dimensions, informativeness and readability. Text characteristics were collected from both subjective ratings and quantitative summary. The results suggested common clinical elements such as templates, headings and inserted objects had strong positive association with document quality. Understanding of such relationship may prove useful in future EHR design and informatics research.

A taxonomy for contextual information in electronic health records.

Contextual information is functional, social and financial information about patients and is central to many health-care decisions, including end-of-life care, living arrangements, and the aggressiveness of treatment. It is the language of patients when talking about their health and frequently the focus of nursing interventions. In this study, we report the results of a qualitative analysis of interviews of 17 clinicians focusing on their use of contextual information during the process of care, decision-making and documentation. We identified seven characteristics of contextual information relevant to its use in a clinical setting. Implications for Natural Language Processing and Ontology construction are discussed.

The orderly and effective visit: impact of the electronic health record on modes of cognitive control.

The clinical Joint Cognitive System (JCS) includes the clinicians, electronic health record (EHR), and other infrastructure that maintain control in the system in the service of accomplishing clinical goals. The purpose of this study is to examine the relationship between levels of control using the COCOM model (scrambled, opportunistic, tactical, and strategic) and patterns of EHR use. Forty-five primary care visits were observed and audio-recorded. Each was coded for COCOM levels of control (IRR = 90%). Screen changes were recorded and time stamped (as either searching or entering). Levels of control were significantly related to preparation intensity (F (2,23) = 6.62; p=0.01), the number of screen changes involved in both searching (F (2,30) = 6.54; p=0.004), and entering information (F (2,22) = 9.26; p=0.001). Combined with the qualitative data, this pattern of EHR usage indicates that the system as designed may not provide effective cognitive support.

Qualitative analysis of workflow modifications used to generate the reference standard for the 2010 i2b2/VA challenge.

The Department of Veterans Affairs (VA) and the Informatics for Integrating Biology and the Bedside (i2b2) team partnered to generate the reference standard for the 2010 i2b2/VA challenge task on concept extraction, assertion classification, and relation classification. The purpose of this paper is to report an in-depth qualitative analysis of the experience and perceptions of human annotators for these tasks. Transcripts of semi-structured interviews were analyzed using qualitative methods to identify key constructs and themes related to these annotation tasks. Interventions were embedded with these tasks using pre-annotation of clinical concepts and a modified annotation workflow. From the human perspective, annotation tasks involve an inherent conflict between bias, accuracy, and efficiency. This analysis deepens understanding of the biases, complexities and impact of variations in the annotation process that may affect annotation task reliability and reference standard validity that are generalizable for other similar large-scale clinical corpus annotation projects.