Expert Perspectives on Definitions, Drivers and Informatics Contributions to Learning Health Systems.

Learning Health System (LHS) proposes a new paradigm in scientific enterprise to facilitate the rapid movement of data to knowledge (D2K) and knowledge to practice (K2P). Informatics can play a pivotal role in facilitating feedback loops and rapid cycles of learning across D2K and K2P. Though informatics has been acknowledged as a critical component of LHS, it remains unclear how leaders in informatics are conceptualizing its role in promoting LHS. This study sought to gain insights from informatics leaders and experts on their perspectives around role of informatics in LHS. We conducted semi-structured interviews with fourteen informatics leaders across different informatics domains and leadership positions. Our results revealed areas of agreement around key concepts related to LHS as well as opportunities to improve messaging and add clarity to the role of informatics in promoting LHS.

Challenges and Opportunities to Improve the Clinician Experience Reviewing Electronic Progress Notes.

BACKGROUND: High-quality clinical notes are essential to effective clinical communication. However, electronic clinical notes are often long, difficult to review, and contain information that is potentially extraneous or out of date. Additionally, many clinicians write electronic clinical notes using customized templates, resulting in notes with significant variability in structure. There is a need to understand better how clinicians review electronic notes and how note structure variability may impact clinicians' note-reviewing experiences. OBJECTIVE: This article aims to understand how physicians review electronic clinical notes and what impact section order has on note-reviewing patterns. MATERIALS AND METHODS: We conducted an experiment utilizing an electronic health record (EHR) system prototype containing four anonymized patient cases, each composed of nine progress notes that were presented with note sections organized in different orders to different subjects (i.e., Subjective, Objective, Assessment, and Plan, Assessment, Plan, Subjective, and Objective, Subjective, Assessment, Objective, and Plan, and Mixed). Participants, who were mid-level residents and fellows, reviewed the cases and provided a brief summary after reviewing each case. Time-related data were collected and analyzed using descriptive statistics. Surveys were administered and interviews regarding experiences reviewing notes were collected and analyzed qualitatively. RESULTS: Qualitatively, participants reported challenges related to reviewing electronic clinical notes. Experimentally, time spent reviewing notes varied based on the note section organization. Consistency in note section organization improved performance (e.g., less scrolling and searching) compared with Mixed section organization when reviewing progress notes. DISCUSSION: Clinicians face significant challenges reviewing electronic clinical notes. Our findings support minimizing extraneous information in notes, removing information that can be found in other parts of the EHR, and standardizing the display and order of note sections to improve clinicians' note review experience. CONCLUSION: Our findings support the need to improve EHR note design and presentation to support optimal note review patterns for clinicians.

Electronic Progress Note Reading Patterns: An Eye Tracking Analysis.

This study used eye-tracking to understand how the order of note sections influences the way physicians read electronic progress notes. Participants (n = 7) wore an eye-tracking device while reviewing progress notes for four patient cases and then provided a verbal summary. We reviewed and analyzed verbal summaries and eye tracking recordings. Wide variation in reading behaviors existed. There was no relationship between time spent reading a section and section origin of verbal summaries.

Usability Evaluation of Electronic Health Record System around Clinical Notes Usage-An Ethnographic Study.

Background A substantial gap exists between current Electronic Health Record (EHR) usability and potential optimal usability. One of the fundamental reasons for this discrepancy is poor incorporation of a User-Centered Design (UCD) approach during the Graphical User Interface (GUI) development process. Objective To evaluate usability strengths and weaknesses of two widely implemented EHR GUIs for critical clinical notes usage tasks. Methods Twelve Internal Medicine resident physicians interacting with one of the two EHR systems (System-1 at Location-A and System-2 at Location-B) were observed by two usability evaluators employing an ethnographic approach. User comments and observer findings were analyzed for two critical tasks: (1) clinical notes entry and (2) related information-seeking tasks. Data were analyzed from two standpoints: (1) usability references categorized by usability evaluators as positive, negative, or equivocal and (2) usability impact of each feature measured through a 7-point severity rating scale. Findings were also validated by user responses to a post observation questionnaire. Results For clinical notes entry, System-1 surpassed System-2 with more positive (26% vs. 12%) than negative (12% vs. 34%) usability references. Greatest impact features on EHR usability (severity score pertaining to each feature) for clinical notes entry were: autopopulation (6), screen options (5.5), communication (5), copy pasting (4.5), error prevention (4.5), edit ability (4), and dictation and transcription (3.5). Both systems performed equally well on information-seeking tasks and features with greatest impacts on EHR usability were navigation for notes (7) and others (e.g., looking for ancillary data; 5.5). Ethnographic observations were supported by follow-up questionnaire responses. Conclusion This study provides usability-specific insights to inform future, improved, EHR interface that is better aligned with UCD approach.

Usability Evaluation of an EHR's Clinical Notes Interface from the Perspective of Attending and Resident Physicians: An Exploratory Study.

Usability gaps between current and future improved Electronic Health Record (EHR) system designs exist due to insufficient incorporation of User-Centered Design (UCD) principles during System Development Life Cycle (SDLC). Usability of a commercial, inpatient EHR clinical notes documentation interface was analyzed from standpoints of two provider groups employing two standardized patient cases. Both objective and subjective data were collected from attending (n = 6) and resident physicians (n = 8) through usability testing employing a mixed method approach. The study results suggested that (i) EHR usability and desirability is influenced by user characteristics, (ii) workloads associated with H&P and progress notes writing are perceived differently between two groups, (iii) repeated task performance improves user efficiency and (iv) user performance is correlated to their subjective system assessments. Understanding usability of clinical documentation interface from perspectives of two different user groups, provides interface designers with an opportunity to develop an EHR system centered on UCD principles.

A comparative observational study of inpatient clinical note-entry and reading/retrieval styles adopted by physicians.

OBJECTIVE: The objective of this study is to understand physicians' usage of inpatient notes by (i) ascertaining different clinical note-entry and reading/retrieval styles in two different and widely used Electronic Health Record (EHR) systems, (ii) extrapolating potential factors leading to adoption of various note-entry and reading/retrieval styles and (iii) determining the amount of time to task associated with documenting different types of clinical notes. METHODS: In order to answer "what" and "why" questions on physicians' adoption of certain-note-entry and reading/retrieval styles, an ethnographic study entailing Internal Medicine residents, with a mixed data analysis approach was performed. Participants were observed interacting with two different EHR systems in inpatient settings. Data was collected around the use and creation of History and Physical (H&P) notes, progress notes and discharge summaries. RESULTS: The highest variability in template styles was observed with progress notes and the least variability was within discharge summaries, while note-writing styles were most consistent for H&P notes. The first sections to be read in a H&P and progress note were the Chief Complaint and Assessment & Plan sections, respectively. The greatest note retrieval variability, with respect to the order of how note sections were reviewed, was observed with H&P and progress notes. Physician preference for adopting a certain reading/retrieval order appeared to be a function of what best fits their workflow while fulfilling the stimulus demands. The time spent entering H&P, discharge summaries and progress notes were similar in both EHRs. CONCLUSION: This research study unveils existing variability in clinical documentation processes and provides us with important information that could help in designing a next generation EHR Graphical User Interface (GUI) that is more congruent with physicians' mental models, task performance needs, and workflow requirements.