Impact of a prototype visualization tool for new information in EHR clinical documents.

BACKGROUND: EHR clinical document synthesis by clinicians may be time-consuming and error-prone due to the complex organization of narratives, excessive redundancy within documents, and, at times, inadvertent proliferation of data inconsistencies. Development of EHR systems that are easily adaptable to the user's work processes requires research into visualization techniques that can optimize information synthesis at the point of care. OBJECTIVE: To evaluate the effect of a prototype visualization tool for clinically relevant new information on clinicians' synthesis of EHR clinical documents and to understand how the tool may support future designs of clinical document user interfaces. METHODS: A mixed methods approach to analyze the impact of the visualization tool was used with a sample of eight medical interns as they synthesized EHR clinical documents to accomplish a set of four pre-formed clinical scenarios using a think-aloud protocol. RESULTS: Differences in the missing (unretrieved) patient information (2.3±1.2 [with the visualization tool] vs. 6.8±1.2 [without the visualization tool], p = 0.08) and accurate inferences (1.3±0.3 vs 2.3±0.3, p = 0.09) were not statistically significant but suggest some improvement with the new information visualization tool. Despite the non-significant difference in total times to task completion (43±4 mins vs 36±4 mins, p = 0.35) we observed shorter times for two scenarios with the visualization tool, suggesting that the time-saving benefits may be more evident with certain clinical processes. Other observed effects of the tool include more intuitive navigation between patient details and increased efforts towards methodical synthesis of clinical documents. CONCLUSION: Our study provides some evidence that new information visualization in clinical notes may positively influence synthesis of patient information from EHR clinical documents. Our findings provide groundwork towards a more effective display of EHR clinical documents using advanced visualization applications.

Problem Stabilization: A Metric for Problem Improvement in Home Visiting Clients.

BACKGROUND: Public health nurse (PHN) home visiting programs have been widely employed to improve life course trajectories for high risk mothers. Home visiting programs are often lengthy, during which PHNs simultaneously address multiple problems using diverse interventions over several client encounters. To manage PHN caseloads it is critical to understand the trajectory of client improvement and the optimal duration or services. PHN documentation data enable intervention trajectory research for specific client problems. A new metric called problem stabilization is proposed for evaluating interim improvement during PHN home visiting. Problem stabilization is an intervention pattern for a client problem that is characterized by co-occurring actions (i.e. teaching, guidance, and counseling; treatments and procedures; case management; and/or surveillance) during a client encounter; followed by surveillance actions only for that problem during a subsequent client encounter. The purpose of the study was to investigate problem stabilization during home visiting services for high risk mothers. METHODS: A retrospective cohort was created using family home visiting intervention documentation data from a local Midwest public health agency over a six year period (2000-2005). The data set consisted of Omaha System interventions for 720 high risk mothers. Analysis was conducted using descriptive statistics and Kaplan Meier curves. RESULTS: On average 30.1% of the time, client problems stabilized before discharge. Stabilization patterns differed by problem. Time to stabilization was longest for Caretaking/parenting and Antepartum/postpartum problems, and shortest for Residence and Mental health problems. CONCLUSIONS: Problem stabilization, a proposed intermediate outcome of PHN home visiting care, appears to be meaningful in describing client response to PHN intervention. This metric is an example of meaningful use of structured clinical electronic health record data for program evaluation and clinical decision support.

Analysis of free text with omaha system targets in community-based care to inform practice and terminology development.

The Omaha system is one of the most widely used interface terminologies for documentation of community-based care. It is influential in disseminating evidence-based practice and generating data for health care quality research. Thus, it is imperative to ensure that the Omaha system reflects current health care knowledge and practice. The purpose of this study was to evaluate free text associated with Omaha system terms to inform issues with electronic health record system use and future Omaha system standard development. Two years of client records from two diverse sites (a skilled homecare, hospice, and palliative care program and a maternal child health home visiting program) were analyzed for the use of free text as a component of the intervention when structured targets for interventions were not identified. Intervention text entries very commonly contained duplicate "carry forward entries", multiple concepts, mismatched problem focus, or failure to identify an existing appropriate target. Our findings support the need to better address education gaps for clinicians. We identified additional suggested targets for Omaha system problems, and propose new targets for consideration in future Omaha system revisions.

An empiric analysis of omaha system targets.

Interface terminologies used in electronic health records must be re-evaluated and revised to reflect current health care practice and knowledge. To enable future revisions of the Omaha System Intervention Scheme, investigators evaluated formal semantic structure of target terms and concept duplication of problem and target terms. Using linguistic principles and qualitative analysis, five themes were found. A multidimensional formal semantic structure for the intervention target term was proposed. Concept duplication was examined for 16 problem-target matches. Clinical data enabled assessment of the validity of a proposed formal semantic structure and concept duplication. Recommendations are suggested for future development of the Omaha System Intervention Scheme.