Assessing Electronic Health Record (EHR) Use during a Major EHR Transition: An Innovative Mixed Methods Approach.

BACKGROUND: Electronic health record (EHR) transitions are inherently disruptive to healthcare workers who must rapidly learn a new EHR and adapt to altered clinical workflows. Healthcare workers' perceptions of EHR usability and their EHR use patterns following transitions are poorly understood. The Department of Veterans Affairs (VA) is currently replacing its homegrown EHR with a commercial Cerner EHR, presenting a unique opportunity to examine EHR use trends and usability perceptions. OBJECTIVE: To assess EHR usability and uptake up to 1-year post-transition at the first VA EHR transition site using a novel longitudinal, mixed methods approach. DESIGN: A concurrent mixed methods strategy using EHR use metrics and qualitative interview data. PARTICIPANTS: 141 clinicians with data from select EHR use metrics in Cerner Lights On Network®. Interviews with 25 healthcare workers in various clinical and administrative roles. APPROACH: We assessed changes in total EHR time, documentation time, and order time per patient post-transition. Interview transcripts (n = 90) were coded and analyzed for content specific to EHR usability. KEY RESULTS: Total EHR time, documentation time, and order time all decreased precipitously within the first four months after go-live and demonstrated gradual improvements over 12 months. Interview participants expressed ongoing concerns with the EHR's usability and functionality up to a year after go-live such as tasks taking longer than the old system and inefficiencies related to inadequate training and inherent features of the new system. These sentiments did not seem to reflect the observed improvements in EHR use metrics. CONCLUSIONS: The integration of quantitative and qualitative data yielded a complex picture of EHR usability. Participants described persistent challenges with EHR usability 1 year after go-live contrasting with observed improvements in EHR use metrics. Combining findings across methods can provide a clearer, contextualized understanding of EHR adoption and use patterns during EHR transitions.

Eliciting Insights From Chat Logs of the 25X5 Symposium to Reduce Documentation Burden: Novel Application of Topic Modeling.

BACKGROUND: Addressing clinician documentation burden through "targeted solutions" is a growing priority for many organizations ranging from government and academia to industry. Between January and February 2021, the 25 by 5: Symposium to Reduce Documentation Burden on US Clinicians by 75% (25X5 Symposium) convened across 2 weekly 2-hour sessions among experts and stakeholders to generate actionable goals for reducing clinician documentation over the next 5 years. Throughout this web-based symposium, we passively collected attendees' contributions to a chat functionality-with their knowledge that the content would be deidentified and made publicly available. This presented a novel opportunity to synthesize and understand participants' perceptions and interests from chat messages. We performed a content analysis of 25X5 Symposium chat logs to identify themes about reducing clinician documentation burden. OBJECTIVE: The objective of this study was to explore unstructured chat log content from the web-based 25X5 Symposium to elicit latent insights on clinician documentation burden among clinicians, health care leaders, and other stakeholders using topic modeling. METHODS: Across the 6 sessions, we captured 1787 messages among 167 unique chat participants cumulatively; 14 were private messages not included in the analysis. We implemented a latent Dirichlet allocation (LDA) topic model on the aggregated dataset to identify clinician documentation burden topics mentioned in the chat logs. Coherence scores and manual examination informed optimal model selection. Next, 5 domain experts independently and qualitatively assigned descriptive labels to model-identified topics and classified them into higher-level categories, which were finalized through a panel consensus. RESULTS: We uncovered ten topics using the LDA model: (1) determining data and documentation needs (422/1773, 23.8%); (2) collectively reassessing documentation requirements in electronic health records (EHRs) (252/1773, 14.2%); (3) focusing documentation on patient narrative (162/1773, 9.1%); (4) documentation that adds value (147/1773, 8.3%); (5) regulatory impact on clinician burden (142/1773, 8%); (6) improved EHR user interface and design (128/1773, 7.2%); (7) addressing poor usability (122/1773, 6.9%); (8) sharing 25X5 Symposium resources (122/1773, 6.9%); (9) capturing data related to clinician practice (113/1773, 6.4%); and (10) the role of quality measures and technology in burnout (110/1773, 6.2%). Among these 10 topics, 5 high-level categories emerged: consensus building (821/1773, 46.3%), burden sources (365/1773, 20.6%), EHR design (250/1773, 14.1%), patient-centered care (162/1773, 9.1%), and symposium comments (122/1773, 6.9%). CONCLUSIONS: We conducted a topic modeling analysis on 25X5 Symposium multiparticipant chat logs to explore the feasibility of this novel application and elicit additional insights on clinician documentation burden among attendees. Based on the results of our LDA analysis, consensus building, burden sources, EHR design, and patient-centered care may be important themes to consider when addressing clinician documentation burden. Our findings demonstrate the value of topic modeling in discovering topics associated with clinician documentation burden using unstructured textual content. Topic modeling may be a suitable approach to examine latent themes presented in web-based symposium chat logs.

Defining Telehealth for Research, Implementation, and Equity.

When the COVID-19 pandemic spurred a disruption in health care delivery, the role of telehealth shifted from an option to a near necessity to maintain access when in-person care was deemed too risky. Each state and many organizations developed temporary telehealth policies for the COVID-19 emergency, each policy with its own definitions, coverage, government cases, and regulations. As pandemic-era policies are now being replaced with more permanent guidelines, we are presented with an opportunity to reevaluate how telehealth is integrated into routine health care delivery. We believe that the timing and nature of the sequential steps for redefining telehealth are critical and that it is important to develop a clear and agreed-on definition of telehealth and its components at this time. We further suggest a necessary preliminary step is to support clear communication and interoperability throughout the development of this definition. Precise and standardized definitions could create an unambiguous environment for clinical care for both patients and providers while enabling researchers to have more precise control over their investigations of telehealth. A consensus when defining telehealth and its derivatives at this critical stage could create a consistent expectation of care for all patients and those who set the standards of care, as it has for other clinical scenarios with clear guidelines.

Interventions to mitigate EHR and documentation burden in health professions trainees: A scoping review.

BACKGROUND: Health professions trainees (trainees) are unique as they learn a chosen field while working within electronic health records (EHR). Efforts to mitigate EHR burden have been described for the experienced health professional (HP), but less is understood for trainees. EHR or documentation burden (EHR burden) affects trainees, although not all trainees use EHRs, and use may differ for experienced HPs. OBJECTIVES: To develop a model of how interventions to mitigate EHR burden fit within the trainee EHR workflow: the Trainee EHR Burden Model. 1) Examine trainee experiences of interventions aimed at mitigating EHR burden(scoping review). 2) Adapt an existing workflow model by mapping included studies(concept clarification). METHODS: We conducted a 4-database scoping review applying PRISMA-ScR guidance, examining scholarly, peer-reviewed studies that measured trainee experience of interventions to mitigate EHR burden. We conducted a concept clarification categorizing, then mapping studies to workflow model elements. We adapted the model to intervenable points for trainee EHR burden. RESULTS: We identified 11 studies examining interventions to mitigate EHR burden that measured trainee experience. Interventions included: curriculum, training, coaching on the existing EHR for both simulated or live tasks; evaluating scribes' impact; adding devices or technology tailored to rounds; team communication or data presentation at end-of shift handoffs. Interventions had varying effects on EHR burden, most commonly measured through surveys, and less commonly, direct observation. Most studies had limited sample sizes, focused on inpatient settings, and physician trainees. CONCLUSION: Few studies measured trainee perspectives of interventions aiming to mitigate EHR burden. Many studies applied quasi-experimental designs and focused on inpatient settings. The Trainee EHR Burden Model, adapted from an existing workflow model, offers a starting place to situate points of intervention in trainee workflow. Further research is needed to design new interventions targeting stages of HP trainee workflow, in a range of clinical settings.

Defining Documentation Burden (DocBurden) and Excessive DocBurden for All Health Professionals: A Scoping Review.

OBJECTIVES: Efforts to reduce documentation burden (DocBurden) for all health professionals (HP) are aligned with national initiatives to improve clinician wellness and patient safety. Yet DocBurden has not been precisely defined, limiting national conversations and rigorous, reproducible, and meaningful measures. Increasing attention to DocBurden motivated this work to establish a standard definition of DocBurden, with the emergence of excessive DocBurden as a term. METHODS: We conducted a scoping review of DocBurden definitions and descriptions, searching six databases for scholarly, peer-reviewed, and gray literature sources, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extensions for Scoping Review guidance. For the concept clarification phase of work, we used the American Nursing Informatics Association's Six Domains of Burden Framework. RESULTS: A total of 153 articles were included based on a priori criteria. Most articles described a focus on DocBurden, but only 18% (n = 28) provided a definition. We define excessive DocBurden as the stress and unnecessarily heavy work an HP or health care team experiences when usability of documentation systems and documentation activities (i.e., generation, review, analysis, and synthesis of patient data) are not aligned in support of care delivery. A negative connotation was attached to burden without a neutral state in included sources, which does not align with dictionary definitions of burden. CONCLUSION: Existing literature does not distinguish between a baseline or required task load to conduct patient care resulting from usability issues (DocBurden), and the unnecessarily heavy tasks and requirements that contribute to excessive DocBurden. Our definition of excessive DocBurden explicitly acknowledges this distinction, to support development of meaningful measures for understanding and intervening on excessive DocBurden locally, nationally, and internationally.

Toward a responsible future: recommendations for AI-enabled clinical decision support.

BACKGROUND: Integrating artificial intelligence (AI) in healthcare settings has the potential to benefit clinical decision-making. Addressing challenges such as ensuring trustworthiness, mitigating bias, and maintaining safety is paramount. The lack of established methodologies for pre- and post-deployment evaluation of AI tools regarding crucial attributes such as transparency, performance monitoring, and adverse event reporting makes this situation challenging. OBJECTIVES: This paper aims to make practical suggestions for creating methods, rules, and guidelines to ensure that the development, testing, supervision, and use of AI in clinical decision support (CDS) systems are done well and safely for patients. MATERIALS AND METHODS: In May 2023, the Division of Clinical Informatics at Beth Israel Deaconess Medical Center and the American Medical Informatics Association co-sponsored a working group on AI in healthcare. In August 2023, there were 4 webinars on AI topics and a 2-day workshop in September 2023 for consensus-building. The event included over 200 industry stakeholders, including clinicians, software developers, academics, ethicists, attorneys, government policy experts, scientists, and patients. The goal was to identify challenges associated with the trusted use of AI-enabled CDS in medical practice. Key issues were identified, and solutions were proposed through qualitative analysis and a 4-month iterative consensus process. RESULTS: Our work culminated in several key recommendations: (1) building safe and trustworthy systems; (2) developing validation, verification, and certification processes for AI-CDS systems; (3) providing a means of safety monitoring and reporting at the national level; and (4) ensuring that appropriate documentation and end-user training are provided. DISCUSSION: AI-enabled Clinical Decision Support (AI-CDS) systems promise to revolutionize healthcare decision-making, necessitating a comprehensive framework for their development, implementation, and regulation that emphasizes trustworthiness, transparency, and safety. This framework encompasses various aspects including model training, explainability, validation, certification, monitoring, and continuous evaluation, while also addressing challenges such as data privacy, fairness, and the need for regulatory oversight to ensure responsible integration of AI into clinical workflow. CONCLUSIONS: Achieving responsible AI-CDS systems requires a collective effort from many healthcare stakeholders. This involves implementing robust safety, monitoring, and transparency measures while fostering innovation. Future steps include testing and piloting proposed trust mechanisms, such as safety reporting protocols, and establishing best practice guidelines.

Identifying and Addressing Barriers to Implementing Core Electronic Health Record Use Metrics for Ambulatory Care: Virtual Consensus Conference Proceedings.

Precise, reliable, valid metrics that are cost-effective and require reasonable implementation time and effort are needed to drive electronic health record (EHR) improvements and decrease EHR burden. Differences exist between research and vendor definitions of metrics. PROCESS: We convened three stakeholder groups (health system informatics leaders, EHR vendor representatives, and researchers) in a virtual workshop series to achieve consensus on barriers, solutions, and next steps to implementing the core EHR use metrics in ambulatory care. CONCLUSION: Actionable solutions identified to address core categories of EHR metric implementation challenges include: (1) maintaining broad stakeholder engagement, (2) reaching agreement on standardized measure definitions across vendors, (3) integrating clinician perspectives, and (4) addressing cognitive and EHR burden. Building upon the momentum of this workshop's outputs offers promise for overcoming barriers to implementing EHR use metrics.

25 × 5 Symposium to Reduce Documentation Burden: Report-out and Call for Action.

BACKGROUND: The widespread adoption of electronic health records and a simultaneous increase in regulatory demands have led to an acceleration of documentation requirements among clinicians. The corresponding burden from documentation requirements is a central contributor to clinician burnout and can lead to an increased risk of suboptimal patient care. OBJECTIVE: To address the problem of documentation burden, the 25 by 5: Symposium to Reduce Documentation Burden on United States Clinicians by 75% by 2025 (Symposium) was organized to provide a forum for experts to discuss the current state of documentation burden and to identify specific actions aimed at dramatically reducing documentation burden for clinicians. METHODS: The Symposium consisted of six weekly sessions with 33 presentations. The first four sessions included panel presentations discussing the challenges related to documentation burden. The final two sessions consisted of breakout groups aimed at engaging attendees in establishing interventions for reducing clinical documentation burden. Steering Committee members analyzed notes from each breakout group to develop a list of action items. RESULTS: The Steering Committee synthesized and prioritized 82 action items into Calls to Action among three stakeholder groups: Providers and Health Systems, Vendors, and Policy and Advocacy Groups. Action items were then categorized into as short-, medium-, or long-term goals. Themes that emerged from the breakout groups' notes include the following: accountability, evidence is critical, education and training, innovation of technology, and other miscellaneous goals (e.g., vendors will improve shared knowledge databases). CONCLUSION: The Symposium successfully generated a list of interventions for short-, medium-, and long-term timeframes as a launching point to address documentation burden in explicit action-oriented ways. Addressing interventions to reduce undue documentation burden placed on clinicians will necessitate collaboration among all stakeholders.

Combination niacin and statin therapy in primary and secondary prevention of cardiovascular disease.

Statin monotherapy may not be sufficient to reach serum lipid goals in many patients, especially in those with combined lipid abnormalities. Statins cause only a modest increase in high-density lipoprotein cholesterol (HDL)--an established independent protective factor for coronary heart disease (CHD)--and a modest decrease in triglycerides (TG). Niacin is an effective pharmacologic agent for increasing HDL, as well as lowering TG. Used in combination with a statin, niacin provides an option to help patients attain their low-density lipoprotein cholesterol (LDL-C) goals, non-HDL goals, and HDL goals. Based on the National Health and Nutrition Examination Survey, 1999 to 2000, only 12% of the surveyed adult population were under treatment for diagnosed hypercholesterolemia. Furthermore, only 5.4% of the surveyed population had attained goal total cholesterol levels of < 5.2 mmol/I (< 200 mg/dl). Combination therapy offers a means to get more people to goal. This paper reviews the impact of lipid-modifying combination therapy with niacin plus a statin on lipid profile outcomes.

Lightning-induced ventricular fibrillation.

We present a case of a previously healthy 17 year-old white male boy scout who collapsed after a lightning strike, and was found to be in ventricular fibrillation when emergency medical services arrived. The ventricular fibrillation was defibrillated into sinus rhythm after a single direct current (DC) countershock. However, the patient has remained in coma. Commotio cordis, sudden cardiac death from low-energy chest wall impact, is a phenomenon in which an exactly timed and located blow on the chest during the cardiac cycle results in ventricular fibrillation. Commotio cordis and electrical shock can both result in ventricular arrhythmias. We speculate that in this patient, ventricular fibrillation began immediately after the lightning, which probably struck at the peak of the T wave. (Cardiol J 2007; 14: 91-94).