EHR Conversion on the PreOp Care: A Pre-Post Workflow Comparison.

The impact of EHRs conversion on clinicians' daily work is crucial to evaluate the success of the intervention for Hospitals and to yield valuable insights into quality improvement. To assess the impact of different EHR systems on the preoperative nursing workflow, we used a structured framework combining quantitative time and motion study and qualitative cognitive analysis to characterize, visualize and explain the differences before and after an EHR conversion. The results showed that the EHR conversion brought a significant decrease in the patient case time and a reduced percentage of time using EHR. PreOp nurses spent a higher proportion of time caring for the patient, while the important tasks were completed in a more continuous pattern after the EHR conversion. The workflow variance was due to different nurse's cognitive process and the task time change was reduced because of some new interface features in the new EHR systems.

An evaluation of the Veterans Health Administration's clinical reminders system: a national survey of generalists.

BACKGROUND: The Veterans Health Administration (VHA) is a leader in developing computerized clinical reminders (CCRs). Primary care physicians' (PCPs) evaluation of VHA CCRs could influence their future development and use within and outside the VHA. OBJECTIVE: Survey PCPs about usefulness and usability of VHA CCRs. DESIGN AND PARTICIPANTS: In a national survey, VHA PCPs rated on a 7-point scale usefulness and usability of VHA CCRs, and standardized scales (0-100) were constructed. A hierarchical linear mixed (HLM) model predicted physician- and facility-level variables associated with more positive global assessment of CCRs. RESULTS: Four hundred sixty-one PCPs participated (response rate, 69%). Scale Cronbach's alpha ranged from 0.62 to 0.82. Perceptions of VHA CCRs were primarily in the midrange, where higher ratings indicate more favorable attitudes (weighted standardized median, IQR): global assessment (50, 28-61), clinical/situational specificity (29, 17-42), integration with workflow/workload (39, 17-50), training (50, 33-67), VHA's management of CCR use (67, 50-83), design/interface (53, 40-67), perceived role in CCR use (67, 50-83), and self-efficacy (67, 57-78). In a HLM model, design/interface (p < .001), self-efficacy (p < .001), integration with workflow/workload (p < .001), and training (p < .001) were associated with more favorable global assessments of CCRs. Facilities in the west as compared to the south (p = .033), and physicians with academic affiliation (p = .045) had less favorable global assessment of CCRs. CONCLUSIONS: Our systematic assessment of end-users' perceptions of VHA CCRs suggests that CCRs need to be developed and implemented with a continual focus on improvement based on end-user feedback. Potential target areas include better integration into the primary care clinic workflow/workload.

Multi-Method Study of Electronic Health Records Workflows.

EHRs transform work practices in ways that enhance or impede the quality of care. There is a need for in-depth analysis of EHR workflows, particularly in complex clinical environments. We investigated EHR-basedpre-operative workflows by combining findings from 18 interviews, 7 days of observations, and process mining of EHR interactions from 31 personnel caring for 375 patients at one tertiary referral center. We provided high-definition descriptions of workflows and personnel roles. One third (32.2%) of the time with each patient was spent interacting with the EHR and 4.2% using paper-based artifacts. We also mined personnel social networks validating observed personnel's EHR-interactions. When comparing workflows between two similar pre-operative settings at different hospitals, we found significant differences in physical organization, patient workflow, roles, use of EHR, social networks and time efficiency. This study informs Mayo Clinic's enterprise-wide conversion to a single EHR and will guide before and after workflow comparisons.

In Search of Vital Signs: A Comparative Study of EHR Documentation.

Vital sign documentation is an essential part of perioperative workflow. Health information technology can introduce complexity into all facets of documentation and burden clinicians with high cognitive load3-4. The Mayo Clinic enterprise is in the process of documenting current EHR-mediated workflow prior to a system-wide EHR conversion. We compared and evaluated three different vital sign documentation interfaces in pre-operative nursing assessments at three different Mayo Clinic sites. The interfaces differed in their modes of interaction, organization of patient information and cognitive support. Analyses revealed that accessing displays and the organization of interface elements are often unintuitive and inefficient, creating unnecessary complexities when interacting with the system. These differences surface through interface workflow models and interactive behavior measures for accessing, logging and reviewing patient information. Different designs differentially mediate task performance, which can ultimately mitigate errors for complex cognitive tasks, risking patient safety. Identifying barriers to interface usability and bottlenecks in EHR-mediated workflow can lead to system redesigns that minimize cognitive load while improving patient safety and efficiency.

Information technology to support improved care for chronic illness.

BACKGROUND: In populations with chronic illness, outcomes improve with the use of care models that integrate clinical information, evidence-based treatments, and proactive management of care. Health information technology is believed to be critical for efficient implementation of these chronic care models. Health care organizations have implemented information technologies, such as electronic medical records, to varying degrees. However, considerable uncertainty remains regarding the relative impact of specific informatics technologies on chronic illness care. OBJECTIVE: To summarize knowledge and increase expert consensus regarding informatics components that support improvement in chronic illness care. DESIGN: A systematic review of the literature was performed. "Use case" models were then developed, based on the literature review, and guidance from clinicians and national quality improvement projects. A national expert panel process was conducted to increase consensus regarding information system components that can be used to improve chronic illness care. RESULTS: The expert panel agreed that informatics should be patient-centered, focused on improving outcomes, and provide support for illness self-management. They concurred that outcomes should be routinely assessed, provided to clinicians during the clinical encounter, and used for population-based care management. It was recommended that interactive, sequential, disorder-specific treatment pathways be implemented to quickly provide clinicians with patient clinical status, treatment history, and decision support. CONCLUSIONS: Specific informatics strategies have the potential to improve care for chronic illness. Software to implement these strategies should be developed, and rigorously evaluated within the context of organizational efforts to improve care.

Connecting the dots: creation of an electronic regional infection control network.

The prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococci (VRE) continues to increase dramatically worldwide. Successful programs to reduce infection rates of resistant organisms require regional or national compliance with strict infection control measures and feedback on implementation and reduced rates. We partnered with local infection control professionals (ICPs) and leveraged our existing electronic network to create a comprehensive city-wide network to track and uniformly respond to patients admitted with a history of MRSA or VRE. We successfully standardized and included electronic data from four out of six of the major healthcare systems within Indianapolis. We created tailored abstracts to deliver key infection control data to ICPs when a MRSA patient is admitted to a participating hospital. We created web-based data entry forms for ICPs to modify and enter new infection control data. This paper describes our design and initial implementation of a working electronic regional infection control network.

Patients' Experiences Using a Brief Screening Tool for Medication-Related Problems in a Community Pharmacy Setting.

OBJECTIVES: The objective of this study was to explore patient perceptions and the practical implication of using a brief 9-item scale to screen for medication-related problems in community pharmacies. METHODS: Semistructured, audio-recorded, telephonic interviews were conducted with 40 patients who completed the scale and reviewed its results with their pharmacist. Audio recordings were transcribed verbatim and analyzed using qualitative methods to identify themes. RESULTS: Patients generally reported the scale was simple to complete and could be used easily in other community pharmacies. Participants shared they had increased understanding of their medications and confidence that their medication therapy was appropriate. Several patients reported having actual medication-related problems identified and resolved through the use of the scale. Patients also reported improved relationships with pharmacists and heightened belief in the value provided by pharmacists. CONCLUSIONS: This screening tool may have value in increasing patients' understanding of and confidence in their medications, enhancing pharmacist-patient relationships, and identifying problems requiring additional interventions.

Evidence-based Health Informatics Frameworks for Applied Use.

Health Informatics frameworks have been created surrounding the implementation, optimization, adoption, use and evaluation of health information technology including electronic health record systems and medical devices. In this contribution, established health informatics frameworks are presented. Important considerations for each framework are its purpose, component parts, rigor of development, the level of testing and validation its undergone, and its limitations. In order to understand how to use a framework effectively, it's often necessary to seek additional explanation via literature, documentation, and discussions with the developers.

A Multidimensional Data Warehouse for Community Health Centers.

Community health centers (CHCs) play a pivotal role in healthcare delivery to vulnerable populations, but have not yet benefited from a data warehouse that can support improvements in clinical and financial outcomes across the practice. We have developed a multidimensional clinic data warehouse (CDW) by working with 7 CHCs across the state of Indiana and integrating their operational, financial and electronic patient records to support ongoing delivery of care. We describe in detail the rationale for the project, the data architecture employed, the content of the data warehouse, along with a description of the challenges experienced and strategies used in the development of this repository that may help other researchers, managers and leaders in health informatics. The resulting multidimensional data warehouse is highly practical and is designed to provide a foundation for wide-ranging healthcare data analytics over time and across the community health research enterprise.

Utility of a brief screening tool for medication-related problems.

BACKGROUND: Medication therapy management (MTM) services position pharmacists to prevent, detect, and resolve medication-related problems (MRPs.) However, selecting patients for MTM who are most at risk for MRPs is a challenge. Using self-administered scales that are practical for use in clinical practice are one approach. OBJECTIVE: The objective of this study was to estimate the psychometric properties of a brief self-administered scale as a screening tool for MRPs. METHODS: This was a non-randomized study utilizing questionnaires administered cross-sectionally. In Phase 1, patients (n = 394) at community pharmacies and outpatient clinics completed 78 items, provided to the study team by item authors, assessing perceived MRPs. These data were used to select items for further investigation as a brief, self-administered scale, and estimate the reliability and construct validity of the resulting instrument. In Phase 2, a convenience sample of patients (n = 200) at community pharmacies completed a nine-item, self-administered scale. After completion, they were engaged in a comprehensive medication review by their pharmacist who was blinded to questionnaire responses. The main outcome measure for estimating the criterion-related validity of the scale was the number of pharmacist-identified medication-related problems (MRPs.) Item statistics were computed as well as bivariate associations between scale scores and other variables with MRPs. A multivariate model was constructed to examine the influence of scale scores on MRPs after controlling for other significant variables. RESULTS: Higher scores on the questionnaire were positively correlated with more pharmacist-identified MRPs (r = 0.24; P = 0.001) and scores remained as a significant predictor (P = 0.031) when controlling for other relevant variables in a multivariate regression model (R(2) = 0.21; P < 0.001). CONCLUSIONS: Patient responses on the scale may have a modest role in predicting MRPs. The use of self-administered questionnaires such as this may supplement other available patient data in developing patient eligibility criteria for MTM, however, additional research is warranted.

Patient-centered appointment scheduling using agent-based simulation.

Enhanced access and continuity are key components of patient-centered care. Existing studies show that several interventions such as providing same day appointments, walk-in services, after-hours care, and group appointments, have been used to redesign the healthcare systems for improved access to primary care. However, an intervention focusing on a single component of care delivery (i.e. improving access to acute care) might have a negative impact other components of the system (i.e. reduced continuity of care for chronic patients). Therefore, primary care clinics should consider implementing multiple interventions tailored for their patient population needs. We collected rapid ethnography and observations to better understand clinic workflow and key constraints. We then developed an agent-based simulation model that includes all access modalities (appointments, walk-ins, and after-hours access), incorporate resources and key constraints and determine the best appointment scheduling method that improves access and continuity of care. This paper demonstrates the value of simulation models to test a variety of alternative strategies to improve access to care through scheduling.

OpenMRS, a global medical records system collaborative: factors influencing successful implementation.

OpenMRS is an open-source, robust electronic health record (EHR) platform that is supported by a large global network and used in over forty countries. We explored what factors lead to successful implementation of OpenMRS in resource constrained settings. Data sources included in-person and telephone key informant interviews, focus groups and responses to an electronic survey from 10 sites in 7 countries. Qualitative data was coded through independent coding, discussion and consensus. The most common perceived benefits of implementation were for providing clinical care, reporting to funders, managing operations and research. Successful implementation factors include securing adequate infrastructure, and sociotechnical system factors, particularly adequate staffing, computers, and ability to use software. Strategic and tactical planning were successful strategies, including understanding and addressing the infrastructure and human costs involved, training or hiring personnel technically capable of modifying the software and integrating it into the daily work flow to meet clinicians' needs.

An operational citywide electronic infection control network: results from the first year.

The prevalence of drug resistant bacteria such as Methicillin-resistant Staphylococcus aureus (MRSA) continues to increase nationwide. Infection control is a regional problem, particularly in urban settings, requiring a coordinated effort. To enable coordinated infection control efforts, we created a citywide electronic notification system to prospectively track and share information regarding all known patients with MRSA. We currently track almost 17,000 patients with a history of MRSA infection or colonization across the Indianapolis region. Since May 2007, we have delivered 2698 admission alerts on patients with a history of MRSA, one-fifth of which (19%) were based on data from another institution. Our system delivers alerts to 20 infection control providers (ICPs) spanning 16 hospital in five different systems across Indianapolis. Electronic coordination of regional infection control information appears to be a critical step to reduce infection rates across an urban population.