Automation in health care: the need for an ergonomics-based approach.

Healthcare quality and efficiency challenges degrade outcomes and burden multiple stakeholders. Workforce shortage, burnout, and complexity of workflows necessitate effective support for patients and providers. There is interest in employing automation, or the use of 'computer[s] [to] carry out… functions that the human operator would normally perform', in health care to improve delivery of services. However, unique aspects of health care require analysis of workflows across several domains and an understanding of the ways work system factors interact to shape those workflows. Ergonomics has identified key work system issues relevant to effective automation in other industries. Understanding these issues in health care can direct opportunities for the effective use of automation in health care. This article illustrates work system considerations using two example workflows; discusses how those considerations may inform solution design, implementation, and use; and provides future directions to advance the essential role of ergonomics in healthcare automation.

This article highlights the essential role of ergonomics in the effective design, implementation, and use of automation in health care. By discussing unique considerations for automation in health care and through two illustrative examples, we demonstrate the importance of an ergonomics approach for developing automated healthcare solutions.

Priorities to accelerate workflow automation in health care.

Inefficient workflows affect many health care stakeholders including patients, caregivers, clinicians, and staff. Widespread health information technology adoption and modern computing provide opportunities for more efficient health care workflows through automation. The Office of the National Coordinator for Health Information Technology (ONC) led a multidisciplinary effort with stakeholders across health care and experts in industrial engineering, computer science, and finance to explore opportunities for automation in health care. The effort included semistructured key informant interviews, a review of relevant literature, and a workshop to understand automation lessons across nonhealth care industries that could be applied to health care. In this article, we describe considerations for advancing workflow automation in health care that were identified through these activities. We also discuss a set of six priorities and related strategies developed through the ONC-led effort and highlight the role the informatics and research communities have in advancing each priority and the strategies.

Phase 1 of the NIH Preprint Pilot: Testing the viability of making preprints discoverable in PubMed Central and PubMed.

Introduction: The National Library of Medicine (NLM) launched a pilot in June 2020 to 1) explore the feasibility and utility of adding preprints to PubMed Central (PMC) and making them discoverable in PubMed and 2) to support accelerated discoverability of NIH-supported research without compromising user trust in NLM's widely used literature services. Methods: The first phase of the Pilot focused on archiving preprints reporting NIH-supported SARS-CoV-2 virus and COVID-19 research. To launch Phase 1, NLM identified eligible preprint servers and developed processes for identifying NIH-supported preprints within scope in these servers. Processes were also developed for the ingest and conversion of preprints in PMC and to send corresponding records to PubMed. User interfaces were modified for display of preprint records. NLM collected data on the preprints ingested and discovery of preprint records in PMC and PubMed and engaged users through focus groups and a survey to obtain direct feedback on the Pilot and perceptions of preprints. Results: Between June 2020 and June 2022, NLM added more than 3,300 preprint records to PMC and PubMed, which were viewed 4 million times and 3 million times, respectively. Nearly a quarter of preprints in the Pilot were not associated with a peer-reviewed published journal article. User feedback revealed that the inclusion of preprints did not have a notable impact on trust in PMC or PubMed. Discussion: NIH-supported preprints can be identified and added to PMC and PubMed without disrupting existing operations processes. Additionally, inclusion of preprints in PMC and PubMed accelerates discovery of NIH research without reducing trust in NLM literature services. Phase 1 of the Pilot provided a useful testbed for studying NIH investigator preprint posting practices, as well as knowledge gaps among user groups, during the COVID-19 public health emergency, an unusual time with heightened interest in immediate access to research results.

HL7 FHIR-based tools and initiatives to support clinical research: a scoping review.

OBJECTIVES: The HL7® fast healthcare interoperability resources (FHIR®) specification has emerged as the leading interoperability standard for the exchange of healthcare data. We conducted a scoping review to identify trends and gaps in the use of FHIR for clinical research. MATERIALS AND METHODS: We reviewed published literature, federally funded project databases, application websites, and other sources to discover FHIR-based papers, projects, and tools (collectively, "FHIR projects") available to support clinical research activities. RESULTS: Our search identified 203 different FHIR projects applicable to clinical research. Most were associated with preparations to conduct research, such as data mapping to and from FHIR formats (n = 66, 32.5%) and managing ontologies with FHIR (n = 30, 14.8%), or post-study data activities, such as sharing data using repositories or registries (n = 24, 11.8%), general research data sharing (n = 23, 11.3%), and management of genomic data (n = 21, 10.3%). With the exception of phenotyping (n = 19, 9.4%), fewer FHIR-based projects focused on needs within the clinical research process itself. DISCUSSION: Funding and usage of FHIR-enabled solutions for research are expanding, but most projects appear focused on establishing data pipelines and linking clinical systems such as electronic health records, patient-facing data systems, and registries, possibly due to the relative newness of FHIR and the incentives for FHIR integration in health information systems. Fewer FHIR projects were associated with research-only activities. CONCLUSION: The FHIR standard is becoming an essential component of the clinical research enterprise. To develop FHIR's full potential for clinical research, funding and operational stakeholders should address gaps in FHIR-based research tools and methods.

A research agenda to support the development and implementation of genomics-based clinical informatics tools and resources.

OBJECTIVE: The Genomic Medicine Working Group of the National Advisory Council for Human Genome Research virtually hosted its 13th genomic medicine meeting titled "Developing a Clinical Genomic Informatics Research Agenda". The meeting's goal was to articulate a research strategy to develop Genomics-based Clinical Informatics Tools and Resources (GCIT) to improve the detection, treatment, and reporting of genetic disorders in clinical settings. MATERIALS AND METHODS: Experts from government agencies, the private sector, and academia in genomic medicine and clinical informatics were invited to address the meeting's goals. Invitees were also asked to complete a survey to assess important considerations needed to develop a genomic-based clinical informatics research strategy. RESULTS: Outcomes from the meeting included identifying short-term research needs, such as designing and implementing standards-based interfaces between laboratory information systems and electronic health records, as well as long-term projects, such as identifying and addressing barriers related to the establishment and implementation of genomic data exchange systems that, in turn, the research community could help address. DISCUSSION: Discussions centered on identifying gaps and barriers that impede the use of GCIT in genomic medicine. Emergent themes from the meeting included developing an implementation science framework, defining a value proposition for all stakeholders, fostering engagement with patients and partners to develop applications under patient control, promoting the use of relevant clinical workflows in research, and lowering related barriers to regulatory processes. Another key theme was recognizing pervasive biases in data and information systems, algorithms, access, value, and knowledge repositories and identifying ways to resolve them.

HITECH to 21st century cures: clinician burden and evolving health IT policy.

Adoption and use of health information technology (IT) was identified as 1 solution to quality and safety issues that permeate the United States health care system. Implementation of health IT has accelerated across the US over the past decade, in part, as a result of legislative and regulatory requirements and incentives. However, adoption of these systems has burdened clinician users due to design, configuration, and implementation issues, resulting in poor usability, challenges to workflow integration, and cumbersome documentation requirements. The path to alleviating these clinician burdens requires a clear understanding of the intent and evolution of pertinent regulations and the context in which they exist. This article reviews the Office of the National Coordinator of Health Information Technology's efforts, documents current regulatory actions, and discusses additional policy opportunities that can further improve clinician satisfaction and effectiveness in providing health care with health IT that is an asset, not an obstacle.

Identifying Opportunities for Workflow Automation in Health Care: Lessons Learned from Other Industries.

BACKGROUND: Workflow automation, which involves identifying sequences of tasks that can be streamlined by using technology and modern computing, offers opportunities to address the United States health care system's challenges with quality, safety, and efficiency. Other industries have successfully implemented workflow automation to address these concerns, and lessons learned from those experiences may inform its application in health care. OBJECTIVE: Our aim was to identify and synthesize (1) current approaches in workflow automation across industries, (2) opportunities for applying workflow automation in health care, and (3) considerations for designing and implementing workflow automation that may be relevant to health care. METHODS: We conducted a targeted review of peer-reviewed and gray literature on automation approaches. We identified relevant databases and terms to conduct the searches across sources and reviewed abstracts to identify 123 relevant articles across 11 disciplines. RESULTS: Workflow automation is used across industries such as finance, manufacturing, and travel to increase efficiency, productivity, and quality. We found automation ranged from low to full automation, and this variation was associated with task and technology characteristics. The level of automation is linked to how well a task is defined, whether a task is repetitive, the degree of human intervention and decision-making required, and the sophistication of available technology. We found that identifying automation goals and assessing whether those goals were reached was critical, and ongoing monitoring and improvement would help to ensure successful automation. CONCLUSION: Use of workflow automation in other industries can inform automating health care workflows by considering the critical role of people, process, and technology in design, testing, implementation, use, and ongoing monitoring of automated workflows. Insights gained from other industries will inform an interdisciplinary effort by the Office of the National Coordinator for Health Information Technology to outline priorities for advancing health care workflow automation.

Fast-Tracking Health Data Standards Development and Adoption in Real-World Settings: A Pilot Approach.

BACKGROUND: Pilot-testing is important in standards development because it facilitates agile navigation of the gap between needs for and use of standards in real-world settings and can reveal the practicalities of implementation. As the implementation and use of health data standards are usually more complicated than anticipated, the Office of the National Coordinator for Health Information Technology (ONC) routinely oversees and organizes relevant pilot projects. OBJECTIVES: This article provides an in-depth look into a sample of ONC's standards-focused pilot projects to (1) inform readers of the complexities of developing, implementing, and advancing standards and (2) guide those seeking to evaluate new standards through pilot projects. METHODS: The ONC's approach to conducting pilot projects begins with identifying a clinical care need, research requirement, or policy outcome that is not well supported by existing standards through a landscape review. ONC then selects a testing approach based on the identified need and maturity of relevant standards. Next, ONC identifies use cases and sites to pilot-test the relevant standard. Once complete, ONC publishes a report that informs subsequent projects and standards development. RESULTS: Pilot projects presented here are organized into three categories related to their demonstrated focus and related approach: (1) improving standards for presenting and sharing clinical genetic data, (2) accelerating the development and implementation of new standards, and (3) facilitating clinical data reuse. Each project illustrates the pilot approach from inception to next steps, capturing the role of collaboration among standards development organizations, stakeholders, and end-users to ensure standards are practical and fit for purpose. CONCLUSION: The ONC approach identifies implementation difficulties prior to broader adoption and use of standards, and provides insight into the steps needed to scale use of standards. The ONC's organization of pilot projects serves as a natural accelerator for building communities of practice, often providing a well-connected beneficiary of lessons learned.

Meeting the challenge: Health information technology's essential role in achieving precision medicine.

Precision medicine can revolutionize health care by tailoring treatments to individual patient needs. Advancing precision medicine requires evidence development through research that combines needed data, including clinical data, at an unprecedented scale. Widespread adoption of health information technology (IT) has made digital clinical data broadly available. These data and information systems must evolve to support precision medicine research and delivery. Specifically, relevant health IT data, infrastructure, clinical integration, and policy needs must be addressed. This article outlines those needs and describes work the Office of the National Coordinator for Health Information Technology is leading to improve health IT through pilot projects and standards and policy development. The Office of the National Coordinator for Health Information Technology will build on these efforts and continue to coordinate with other key stakeholders to achieve the vision of precision medicine. Advancement of precision medicine will require ongoing, collaborative health IT policy and technical initiatives that advance discovery and transform healthcare delivery.

Opportunities for the use of health information technology to support research.

In the last decade, expanding use of health information technology (IT) across the United States has created opportunities for use of electronic health data for health services and biomedical research, but efforts may be hampered by limited data access, data quality, and system functionality. We identify five opportunities to advance the use of health IT for health services and biomedical research, which informed a federal government-led, collaborative effort to develop a relevant policy and development agenda. In particular, the health IT infrastructure should more effectively support the use of electronic health data for research; provide adaptable technologies; incorporate relevant research-related functionality; support patient and caregiver engagement in research; and support effective integration of knowledge into practice. While not exhaustive, these represent important opportunities that the biomedical and health informatics communities can pursue to better leverage health IT and electronic health data for research.

The national health information technology human factors and ergonomics agenda.

Health information technology (IT) implementation has encompassed much of the United States health care system over the past decade, and user frustration with health IT has steadily increased. Human factors and ergonomics (HFE) methods and approaches can improve the design, implementation, and use of health IT for clinicians and consumers. To better understand the effect of federal HFE in health IT research funding, the authors conducted a review of several key, specific initiatives. The review focused on the goals and accomplishments of these initiatives. Findings to date show that HFE is improving the usefulness of health IT, but additional research and new methods are needed. Corresponding research funding and policy priorities are identified. New HFE work and innovative approaches are needed to capitalize on HFE knowledge, principles, and methods to improve the design, implementation, and use of health IT at a broader scale.

National health information technology priorities for research: A policy and development agenda.

The growth of digitized health data presents exciting opportunities to leverage the health information technology (IT) infrastructure for advancing biomedical and health services research. However, challenges impede use of those resources effectively and at scale to improve outcomes. The Office of the National Coordinator for Health Information Technology (ONC) led a collaborative effort to identify challenges, priorities, and actions to leverage health IT and electronic health data for research. Specifically, ONC led a review of relevant literature and programs, key informant interviews, and a stakeholder workshop to identify electronic health data and health IT infrastructure gaps. This effort resulted in the National Health IT Priorities for Research: A Policy and Development Agenda, which articulates an optimized health information ecosystem for scientific discovery. This article outlines 9 priorities and recommended actions to be implemented in collaboration with the research and informatics communities for realizing this vision.

Sync for Genes: Making Clinical Genomics Available for Precision Medicine at the Point-of-Care.

BACKGROUND: Making genomic data available at the point-of-care and for research is critical for the success of the Precision Medicine Initiative (PMI), a research initiative which seeks to change health care by "tak(ing) into account individual differences in people's genes, environments, and lifestyles." The Office of the National Coordinator for Health Information Technology (ONC) led Sync for Genes, a program to develop standards that make genomic data available when and where it matters most. This article discusses lessons learned from recent Sync for Genes activities. OBJECTIVES: The goals of Sync for Genes were to (1) demonstrate exchange of genomic data using health data standards, (2) provide feedback for refinement of health data standards, and (3) synthesize project experiences to support the integration of genomic data at the point-of-care and for research. METHODS: Four organizations participated in a program to test the Health Level Seven International (HL7®) Fast Healthcare Interoperability Resources (FHIR®) standard, which supports sharing genomic data. ONC provided access to subject matter experts, resources, tools, and technical guidance to support testing activities. Three of the four organizations participated in HL7 FHIR Connectathons to test FHIR's ability to exchange genomic diagnostic reports. RESULTS: The organizations successfully demonstrated exchange of genomic diagnostic reports using FHIR. The feedback and artifacts that resulted from these activities were shared with HL7 and made publicly available. Four areas were identified as important considerations for similar projects: (1) FHIR proficiency, (2) developer support, (3) project scope, and (4) bridging health information technology and genomic expertise. CONCLUSION: Precision medicine is a rapidly evolving field, and there is opportunity to continue maturing health data standards for the exchange of necessary genomic data, increasing the likelihood that the standard supports the needs of users.

Leveraging the health information technology infrastructure to advance federal research priorities.

Ensuring that federally funded health research keeps pace with the explosion of health data depends on better information technology (IT), access to high-quality electronic health data, and supportive policies. Because it prominently funds and conducts health research, the U.S. federal government needs health IT to rapidly evolve and has the ability to drive that evolution. The Office of the National Coordinator for Health Information Technology developed the National Health IT Priorities for Research: A Policy and Development Agenda (the Agenda) that identifies health IT priorities for research in consultation with relevant federal agencies. This article describes support for the Agenda from the Food and Drug Administration, the National Institutes of Health, and the Veterans Health Administration. Advancing the Agenda will benefit these agencies and support their missions as well as the entire ecosystem leveraging the health IT infrastructure or using data from health IT systems for research.

Health information management in the home: a human factors assessment.

OBJECTIVE: Achieving optimal health outcomes requires that consumers maintain myriad health data and understand how to utilize appropriate health information management applications. This case study investigated four families' health information management tasks in their homes. PARTICIPANTS: Four different families participated in the study: a single parent household; two nuclear family households; and an extended family household. METHODS: A work system model known as the balance model was used as a guiding framework for data collection. Data collection consisted of three stages: (1) primary health information manager interviews; (2) family interviews; and (3) task observations. RESULTS: Overall, families reported 69 unique health information management tasks that took place in nine different locations, using 22 different information storage artifacts. Frequently occurring tasks related to health management or health coordination were conducted in public spaces. Less frequent or more time-consuming tasks, such as researching a health concern or storing medical history, were performed in private spaces such as bedrooms or studies. CONCLUSIONS: Similarities across households suggest potential foundational design elements that consumer health information technology application designers need to balance with tailored interventions to successfully support variations in individuals' health information management needs.

Commercial off-the-shelf consumer health informatics interventions: recommendations for their design, evaluation and redesign.

OBJECTIVE: The goal of this paper is to describe the successful application of a use case-based evaluation approach to guide the effective design, evaluation and redesign of inexpensive, commercial, off-the-shelf consumer health informatics (CHI) interventions. DESIGN: Researchers developed four CHI intervention use cases representing two distinct patient populations (patients with diabetes with high blood pressure, post-bariatric surgery patients), two commercial off-the-shelf CHI applications (Microsoft HealthVault, Google Health), and related devices (blood pressure monitor, pedometer, weight scale). Three patient proxies tested each intervention for 10 days. MEASUREMENTS: The patient proxies recorded their challenges while completing use case tasks, rating the severity of each challenge based on how much it hindered their use of the intervention. Two independent evaluators categorized the challenges by human factors domain (physical, cognitive, macroergonomic). RESULTS: The use case-based approach resulted in the identification of 122 challenges, with 12% physical, 50% cognitive and 38% macroergonomic. Thirty-nine challenges (32%) were at least moderately severe. Nine of 22 use case tasks (41%) accounted for 72% of the challenges. LIMITATIONS: The study used two patient proxies and addressed two specific patient populations and low-cost, off-the-shelf CHI interventions, which may not perfectly generalize to a larger number of proxies, actual patient populations, or other CHI interventions. CONCLUSION: CHI designers can employ the use case-based evaluation approach to assess the fit of a CHI intervention with patients' health work, in the context of their daily activities and environment, which would be difficult or impossible to evaluate by laboratory-based studies.

Considerations for the design of safe and effective consumer health IT applications in the home.

INTRODUCTION: Consumer health IT applications have the potential to improve quality, safety and efficiency of consumers' interactions with the healthcare system. Yet little attention has been paid to human factors and ergonomics in the design of consumer health IT, potentially limiting the ability of health IT to achieve these goals. This paper presents the results of an analysis of human factors and ergonomics issues encountered by five projects during the design and implementation of home-based consumer health IT applications. METHODS: Agency for Healthcare Research and Quality-funded consumer health IT research projects, where patients used the IT applications in their homes, were reviewed. Project documents and discussions with project teams were analysed to identify human factors and ergonomic issues considered or addressed by project teams. The analysis focused on system design and design processes used as well as training, implementation and use of the IT intervention. RESULTS: A broad range of consumer health IT applications and diverse set of human factors and ergonomics issues were identified. The design and implementation processes used resulted in poor fit with some patients' healthcare tasks and the home environment and, in some cases, resulted in lack of use. Clinician interaction with patients and the information provided through health IT applications appeared to positively influence adoption and use. CONCLUSIONS: Consumer health IT application design would benefit from the use of human factors and ergonomics design and evaluation methods. Considering the context in which home-based consumer health IT applications are used will likely affect the ability of these applications to positively impact the quality, safety and efficiency of patient care.

Information gap: can health insurer personal health records meet patients' and physicians' needs?

Personal health records (PHRs), centralized places for people to electronically store and organize their health information, can benefit both patients and doctors. This qualitative study of health insurers' PHRs for enrollees reveals potential benefits and challenges. Insurers' ability to put claims-based data into the PHR offers an advantage. However, consumers are concerned about sharing personal health information with insurers and about Internet security. Physicians question (1) the validity of claims data in making treatment decisions and (2) whether accessing these PHRs is worth the disruptions to their workflow. This paper offers possible solutions that may lead to more widespread adoption of insurer PHRs.

The human factors of home health care: a conceptual model for examining safety and quality concerns.

OBJECTIVE: Increases in longevity, a growing elderly population, variation of skill and knowledge among home providers, and a steady migration of medical devices and technologies into the home are placing new demands on home heath care. The paper examines the human factors challenges associated with these converging trends. METHODS: A growing literature base relevant to home health care is examined, and with the aid of a socio-technical systems model, the paper explores safety and quality concerns to which the converging trends are likely to give rise. FINDINGS: The sensory, physical, and cognitive limitations of patients and their caregivers play a key role in the ability of patients to manage home health care needs. Other major components affecting successful home health care management are the nature of health care tasks undertaken, the design features of the physical environment, the medical devices and technologies used, the social and community environments, and distal but relevant external factors that shape the context of care. Home health care stakeholders can avoid foreseeable threats to safety and quality by recognizing that components need to be designed in a way that takes into account their interactions with one another and with the capabilities and limitations of patients and their providers. CONCLUSIONS: By examining the major components and interdependencies of the home health care delivery system, a human factors perspective offers insights into ways that safety and quality can be compromised and can help pave the way for new modes of thinking in home health care policy.