Studying Workflow and Workarounds in Electronic Health Record-Supported Work to Improve Health System Performance.

Clinical workflow is the enactment of a series of steps to perform a clinical activity. The transition from paper to electronic health records (EHRs) over the past decade has been characterized by profound challenges supporting clinical workflow, impeding frontline clinicians' ability to deliver safe, efficient, and effective care. In response, there has been substantial effort to study clinical workflow as well as workarounds-exceptions to routine workflow-in order to identify opportunities for improvement. This article describes predominant methods of studying workflow and workarounds and provides examples of the applications of these methods along with the resulting insights. Challenges to studying workflow and workarounds are described, and recommendations for how to approach such studies are given. Although there is not yet a set of standard approaches, this article helps advance workflow research that ultimately serves to inform how to coevolve the design of EHR systems and organizational decisions about processes, roles, and responsibilities in order to support clinical workflow that more consistently delivers on the potential benefits of a digitized health care system.

Preliminary Assessment of a Telehealth Approach to Evaluating, Treating, and Discharging Low-Acuity Patients With Suspected COVID-19.

BACKGROUND: Telemedicine is uniquely positioned to address challenges posed to emergency departments (EDs) by the Coronavirus Disease 2019 (COVID-19) pandemic. By reducing in-person contact, it should decrease provider risk of infection and preserve personal protective equipment (PPE). OBJECTIVES: To describe and assess the early results of a novel telehealth workflow in which remote providers collaborate with in-person nursing to evaluate and discharge well-appearing, low-risk ED patients with suspected COVID-19 infection. METHODS: Retrospective chart review was completed 3 weeks after implementation. Metrics include the number of patients evaluated, number of patients discharged without in-person contact, telehealth wait time and duration, collection of testing, ED length of stay (ED-LOS), 72-h return, number of in-person health care provider contacts, and associated PPE use. RESULTS: Among 302 patients evaluated by telehealth, 153 patients were evaluated and discharged by a telehealth provider with reductions in ED-LOS, PPE use, and close contact with health care personnel. These patients had a 62.5% shorter ED-LOS compared with other Emergency Severity Index level 4 patients seen over the same time period. Telehealth use for these 153 patients saved 413 sets of PPE. We observed a 3.9% 72-h revisit rate. One patient discharged after telehealth evaluation was hospitalized on a return visit 9 days later. CONCLUSION: Telehealth can be safely and efficiently used to evaluate, treat, test, and discharge ED patients suspected to have COVID-19. This workflow reduces infection risks to health care providers, PPE use, and ED-LOS. Additionally, it allows quarantined but otherwise well clinicians to continue working.

Workflow Analysis Driven Recommendations for Integration of Electronically-Enhanced Sexually Transmitted Infection Screening Tools in Pediatric Emergency Departments.

Adolescents are disproportionately affected by sexually transmitted infections (STIs). Failure to diagnose and treat STIs in a timely manner may result in serious sequelae. Adolescents frequently access the emergency department (ED) for care. Although ED-based STI screening is acceptable to both patients and clinicians, understanding how best to implement STI screening processes into the ED clinical workflow without compromising patient safety or efficiency is critical. The objective of this study was to conduct direct observations documenting current workflow processes and tasks during patient visits at six Pediatric Emergency Care Applied Research Network (PECARN) EDs for site-specific integration of STI electronically-enhanced screening processes. Workflow observations were captured via TaskTracker, a time and motion electronic data collection application that allows researchers to categorize general work processes and record multitasking by providing a timestamp of when tasks began and ended. Workflow was captured during 118 patient visits across six PECARN EDs. The average time to initial assessment by the most senior provider was 76 min (range 59-106 min, SD = 43 min). Care teams were consistent across sites, and included attending physicians, advanced practice providers, nurses, registration clerks, technicians, and students. A timeline belt comparison was performed. Across most sites, the most promising implementation of a STI screening tool was in the patient examination room following the initial patient assessment by the nurse.

The Radiologist's Gaze: Mapping Three-Dimensional Visual Search in Computed Tomography of the Abdomen and Pelvis.

A radiologist's search pattern can directly influence patient management. A missed finding is a missed opportunity for intervention. Multiple studies have attempted to describe and quantify search patterns but have mainly focused on chest radiographs and chest CTs. Here, we describe and quantify the visual search patterns of 17 radiologists as they scroll through 6 CTs of the abdomen and pelvis. Search pattern tracings varied among individuals and remained relatively consistent per individual between cases. Attendings and trainees had similar eye metric statistics with respect to time to first fixation (TTFF), number of fixations in the region of interest (ROI), fixation duration in ROI, mean saccadic amplitude, or total number of fixations. Attendings had fewer numbers of fixations per second versus trainees (p < 0.001), suggesting efficiency due to expertise. In those cases that were accurately interpreted, TTFF was shorter (p = 0.04), the number of fixations per second and number of fixations in ROI were higher (p = 0.04, p = 0.02, respectively), and fixation duration in ROI was increased (p = 0.02). We subsequently categorized radiologists as "scanners" or "drillers" by both qualitative and quantitative methods and found no differences in accuracy with most radiologists being categorized as "drillers." This study describes visual search patterns of radiologists in interpretation of CTs of the abdomen and pelvis to better approach future endeavors in determining the effects of manipulations such as fatigue, interruptions, and computer-aided detection.

Identifying health information technology related safety event reports from patient safety event report databases.

OBJECTIVE: The objective of this paper was to identify health information technology (HIT) related events from patient safety event (PSE) report free-text descriptions. A difference-based scoring approach was used to prioritize and select model features. A feature-constraint model was developed and evaluated to support the analysis of PSE reports. METHODS: 5287 PSE reports manually coded as likely or unlikely related to HIT were used to train unigram, bigram, and combined unigram-bigram logistic regression and support vector machine models using five-fold cross validation. A difference-based scoring approach was used to prioritize and select unigram and bigram features by their relative importance to likely and unlikely HIT reports. A held-out set of 2000 manually coded reports were used for testing. RESULTS: Unigram models tended to perform better than bigram and combined models. A 300-unigram logistic regression had comparable classification performance to a 4030-unigram SVM model but with a faster relative run-time. The 300-unigram logistic regression model evaluated with the testing data had an AUC of 0.931 and a F1-score of 0.765. DISCUSSION: A difference-based scoring, prioritization, and feature selection approach can be used to generate simplified models with high performance. A feature-constraint model may be more easily shared across healthcare organizations seeking to analyze their respective datasets and customized for local variations in PSE reporting practices. CONCLUSION: The feature-constraint model provides a method to identify HIT-related patient safety hazards using a method that is applicable across healthcare systems with variability in their PSE report structures.

Emergency Physician Use of Cognitive Strategies to Manage Interruptions.

STUDY OBJECTIVE: The purpose of this study is to examine whether emergency physicians use strategies to manage interruptions during clinical work. Interruption management strategies include immediately engaging the interruption by discontinuing the current task and starting the interruption, continuing the current task while engaging the interruption, rejecting the interruption, or delaying the interruption. METHODS: An observational time and motion study was conducted in 3 different urban, academic emergency departments with 18 attending emergency physicians. Each physician was observed for 2 hours, and the number of interruptions, source of interruptions, type of task being interrupted, and use of interruption management strategies were documented. RESULTS: Participants were interrupted on average of 12.5 times per hour. The majority of interruptions were in person from other staff, including nurses, residents, and other attending physicians. When participants were interrupted, they were often working on their computer. Participants almost always immediately engaged the interruption task (75.4% of the time), followed by multitasking, in which the primary task was continued while the interrupting task was performed (22.2%). Physicians rejected or delayed interruptions less than 2% of the time. CONCLUSION: Our results suggest there is an opportunity to introduce emergency physicians to the use of interruption management strategies as a method of handling the frequent interruptions they are exposed to. Use of these strategies when high-risk primary tasks are performed may reduce the disruptiveness of some interruptions and improve patient safety.

Emergency Physician Task Switching Increases With the Introduction of a Commercial Electronic Health Record.

STUDY OBJECTIVE: We evaluate how the transition from a homegrown electronic health record to a commercial one affects emergency physician work activities from initial introduction to long-term use. METHODS: We completed a quasi-experimental study across 3 periods during the transition from a homegrown system to a commercially available electronic health record with computerized provider order entry. Observation periods consisted of pre-implementation, 1 month before the implementation of the commercial electronic health record; "go-live" 1 week after implementation; and post-implementation, 3 to 4 months after use began. Fourteen physicians were observed in each period (N=42) with a minute-by-minute observation template to record emergency physician time allocation across 5 task-based categories (computer, verbal communication, patient room, paper [chart/laboratory results], and other). The average number of tasks physicians engaged in per minute was also analyzed as an indicator of task switching. RESULTS: From pre- to post-implementation, there were no significant differences in the amount of time spent on the various task categories. There were changes in time allocation from pre-implementation to go-live and go-live to pre-implementation, characterized by a significant increase in time spent on computer tasks during go-live relative to the other periods. Critically, the number of tasks physicians engaged in per minute increased from 1.7 during pre-implementation to 1.9 during post-implementation (difference 0.19 tasks per minute; 95% confidence interval 0.039 to 0.35). CONCLUSION: The increase in the number of tasks physicians engaged in per minute post-implementation indicates that physicians switched tasks more frequently. Frequent task switching behavior raises patient safety concerns.

Exploring methods for identifying related patient safety events using structured and unstructured data.

Most healthcare systems have implemented patient safety event reporting systems to identify safety hazards. Searching the safety event data to find related patient safety reports and identify trends is challenging given the complexity and quantity of these reports. Structured data elements selected by the event reporter may be inaccurate and the free-text narrative descriptions are difficult to analyze. In this paper we present and explore methods for utilizing both the unstructured free-text and structured data elements in safety event reports to identify and rank similar events. We evaluate the results of three different free-text search methods, including a unique topic modeling adaptation, and structured element weights, using a patient fall use case. The various search techniques and weight combinations tended to prioritize different aspects of the event reports leading to different search and ranking results. These search and prioritization methods have the potential to greatly improve patient safety officers, and other healthcare workers, understanding of which safety event reports are related.

Development and Evaluation of Patient Safety Interventions: Perspectives of Operational Safety Leaders and Patient Safety Organizations.

OBJECTIVES: The purpose of this study is to understand how patient safety professionals from healthcare facilities and patient safety organizations develop patient safety interventions and the resources used to support intervention development. METHODS: Semistructured interviews were conducted with patient safety professionals at nine healthcare facilities and nine patient safety organizations. Interview data were qualitatively analyzed, and findings were organized by the following: patient safety solutions and interventions, use of external databases, and evaluation of patient safety solutions. RESULTS: Development of patient safety interventions across healthcare facilities and patient safety organizations was similar and included literature searches, internal brainstorming, and interviews. Nearly all patient safety professionals at healthcare facilities reported contacting colleagues at other healthcare facilities to learn about similar safety issues and potential interventions. Additionally, less than half of patient safety professionals at healthcare facilities and patient safety organizations interviewed report data to publicly available patient safety databases. Finally, most patient safety professionals at healthcare facilities and patient safety organizations stated that they evaluate the effectiveness of patient safety interventions; however, they mentioned methods that may be less rigorous including audits, self-reporting, and subjective judgment. CONCLUSIONS: Patient safety professionals often utilize similar methods and resources to develop and evaluate patient safety interventions; however, many of these efforts are not coordinated across healthcare organizations and could benefit from working collectively in a systematic fashion. Additionally, healthcare facilities and patient safety organizations face similar challenges and there are several opportunities for optimization on a national level that may improve patient safety.

Reading Room Interruptions are Less Disruptive When Using Asynchronous Communication Methods.

Radiologist interruptions, though often necessary, can be disruptive. Prior literature has shown interruptions to be frequent, occurring during cases, and predominantly through synchronous communication methods such as phone or in person causing significant disengagement from the study being read. Asynchronous communication methods are now more widely available in hospital systems such as ours. Considering the increasing use of asynchronous communication methods, we conducted an observational study to understand the evolving nature of radiology interruptions. We hypothesize that compared to interruptions occurring through synchronous methods, interruptions via asynchronous methods reduce the disruptive nature of interruptions by occurring between cases, being shorter, and less severe. During standard weekday hours, 30 radiologists (14 attendings, 12 residents, and 4 fellows) were directly observed for approximately 90-min sessions across three different reading rooms (body, neuroradiology, general). The frequency of interruptions was documented including characteristics such as timing, severity, method, and length. Two hundred twenty-five interruptions (43 Teams, 47 phone, 89 in-person, 46 other) occurred, averaging 2 min and 5 s with 5.2 interruptions per hour. Microsoft Teams interruptions averaged 1 min 12 s with only 60.5% during cases. In-person interruptions averaged 2 min 12 s with 82% during cases. Phone interruptions averaged 2 min and 48 s with 97.9% during cases. A substantial portion of reading room interruptions occur via predominantly asynchronous communication tools, a new development compared to prior literature. Interruptions via predominantly asynchronous communications tools are shorter and less likely to occur during cases. In our practice, we are developing tools and mechanisms to promote asynchronous communication to harness these benefits.

Electronic health record "gag clauses" and the prevalence of screenshots in peer-reviewed literature.

OBJECTIVE: To determine whether the Office of the National Coordinator's policy change restricting the use of "gag clauses" in contracts between electronic health record (EHR) vendors and healthcare facilities increased the prevalence of screenshots in peer-reviewed literature. MATERIALS AND METHODS: We reviewed EHR usability and safety-related peer-reviewed journal articles from 2015 to 2023 and quantified the number of articles containing screenshots. For those that did not contain screenshots, we identified whether they would have benefited from screenshots. RESULTS: When gag clauses were permitted 6 of 79 (7.6%) of articles contained screenshots and 8 (10.1%) would have benefited from screenshots. When gag clauses were restricted 3 of 40 (7.5%) contained screenshots and 8 (20%) would have benefited from screenshots. DISCUSSION: The policy change does not appear to have an impact on the prevalence of screenshots in peer-reviewed literature. CONCLUSIONS: Additional steps are necessary to promote the use of screenshots in peer-reviewed literature.

A text mining approach to categorize patient safety event reports by medication error type.

Patient safety reporting systems give healthcare provider staff the ability to report medication related safety events and errors; however, many of these reports go unanalyzed and safety hazards go undetected. The objective of this study is to examine whether natural language processing can be used to better categorize medication related patient safety event reports. 3,861 medication related patient safety event reports that were previously annotated using a consolidated medication error taxonomy were used to develop three models using the following algorithms: (1) logistic regression, (2) elastic net, and (3) XGBoost. After development, models were tested, and model performance was analyzed. We found the XGBoost model performed best across all medication error categories. 'Wrong Drug', 'Wrong Dosage Form or Technique or Route', and 'Improper Dose/Dose Omission' categories performed best across the three models. In addition, we identified five words most closely associated with each medication error category and which medication error categories were most likely to co-occur. Machine learning techniques offer a semi-automated method for identifying specific medication error types from the free text of patient safety event reports. These algorithms have the potential to improve the categorization of medication related patient safety event reports which may lead to better identification of important medication safety patterns and trends.

The impact of COVID-19 on primary care accessibility and the role of telehealth for patients with chronic conditions.

Objectives: The objective of this study is to quantify how long patients took to complete their rescheduled primary care appointment pre-pandemic (2019) and during an initial pandemic period (2020). In doing so, the study evaluates telehealth's role in helping primary care patients - particularly in patients with chronic conditions - withstand COVID's significant disruption in care. Methods: Cancelled and completed primary care appointments for adult patients were extracted from the beginning of the pandemic (March 1 to July 31, 2020) and a similar period pre-pandemic (March 1 to July 31, 2019). Days to the subsequent completed visit after cancellation (through June 30, 2021) and appointment modality (in-person, phone, video) were examined. Statistical testing was done to determine statistical significance, and a linear regression was run to control for effects of other study variables. Results: Pre-pandemic patients with chronic conditions needed 52.3 days on average to reschedule their cancelled in-person appointment. During the early pandemic period, chronic condition patients who saw their provider in-person took on average 78.8 days. During the same pre-pandemic period, patients with chronic conditions had their average wait time decrease to 51.5 days when rescheduling via telehealth. These differences were similar for patients without chronic conditions. Conclusions: This analysis shows that telehealth created return to care timelines comparable to the pre-pandemic period which is especially important for patients with chronic conditions. Public interest summary: Telehealth visits (i.e., talking with a physician via phone or video call) help patients continue to receive the medical care they need - especially during disruptive periods such as the COVID pandemic. Access to telehealth is the strongest predictor in determining how soon a patient will complete their reschedule primary care appointment. Because telehealth is so important, health care providers and systems need to continue to offer patients the ability to talk with their physician via phone or video call.

Electronic Health Record Use Issues and Diagnostic Error: A Scoping Review and Framework.

BACKGROUND: Diagnostic errors are a major source of patient harm, most of which are caused by cognitive errors and biases. Despite research showing the relationship between software systems and cognitive processes, the impact of the electronic health record (EHR) on diagnostic error remains unknown. METHODS: We conducted a scoping review of the scientific literature to (1) survey the association between aspects of the EHR and diagnostic error, and (2) through a human-systems integration lens, identify the types of EHR issues and their impact on the stages of the diagnostic process. RESULTS: We analyzed 11 research articles for the relationship between EHR use and diagnostic error. These articles highlight specific technical, usability, and workflow issues with the EHR that pose risks for diagnostic error at every stage of the diagnostic process. DISCUSSION: Although technical problems such as EHR interoperability and data integrity pose critical issues for the diagnostic process, usability and workflow issues such as poor display design, and inability to track test results also hamper clinicians' ability to track, process, and act in the diagnostic process. Current research methods have limited coverage over clinical settings, are not standardized, and rarely include measures of patient harm. CONCLUSIONS: The available evidence shows that EHRs pose risks for diagnostic error throughout the diagnostic process, with most issues involving their incompatibility with providers' cognitive processing. A structured and systematic model of collecting and reporting on these errors is needed to understand how the EHR shapes the diagnostic process and improve diagnostic accuracy.