Driven to distraction: The nature and apparent purpose of interruptions in critical care and implications for HIT.

OBJECTIVES: To examine the apparent purpose of interruptions in a Pediatric Intensive Care Unit and opportunities to reduce their burden with informatics solutions. MATERIALS AND METHODS: In this prospective observational study, researchers shadowed clinicians in the unit for one hour at a time, recording all interruptions participating clinicians experienced or initiated, their starting time, duration, and a short description that could help to infer their apparent purpose. All captured interruptions were classified inductively on their source and apparent purpose and on the optimal representational media for fulfilling their apparent purpose. RESULTS: The researchers observed thirty-four one-hour sessions with clinicians in the unit, including 21 nurses and 13 residents and house physicians. The physicians were interrupted on average 11.9 times per hour and interrupted others 8.8 times per hour. Nurses were interrupted 8.6 times per hour and interrupted others 5.1 times per hour. The apparent purpose of interruptions included Information Seeking and Sharing (n=259, 46.3%), Directives and Requests (n=70, 12%), Shared Decision-Making (n=49, 8.8%), Direct Patient Care (n=36, 6.4%), Social (n=71, 12.7%), Device Alarms (n=28, 5%), and Non-Clinical (n=10, 1.8%); 6.6% were not classified due to insufficient description. Of all captured interruptions, 29.5% were classified as being better served with informational displays or computer-mediated communication. CONCLUSIONS: Deeper understanding of the purpose of interruptions in critical care can help to distinguish between interruptions that require face-to-face conversation and those that can be eliminated with informatics solutions. The proposed taxonomy of interruptions and representational analysis can be used to further advance the science of interruptions in clinical care.

Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department: a sociotechnical analysis.

Integration of clinical decision support services (CDSS) into electronic health records (EHRs) may be integral to widespread dissemination and use of clinical prediction rules in the emergency department (ED). However, the best way to design such services to maximize their usefulness in such a complex setting is poorly understood. We conducted a multi-site cross-sectional qualitative study whose aim was to describe the sociotechnical environment in the ED to inform the design of a CDSS intervention to implement the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules for children with minor blunt head trauma. Informed by a sociotechnical model consisting of eight dimensions, we conducted focus groups, individual interviews and workflow observations in 11 EDs, of which 5 were located in academic medical centers and 6 were in community hospitals. A total of 126 ED clinicians, information technology specialists, and administrators participated. We clustered data into 19 categories of sociotechnical factors through a process of thematic analysis and subsequently organized the categories into a sociotechnical matrix consisting of three high-level sociotechnical dimensions (workflow and communication, organizational factors, human factors) and three themes (interdisciplinary assessment processes, clinical practices related to prediction rules, EHR as a decision support tool). Design challenges that emerged from the analysis included the need to use structured data fields to support data capture and re-use while maintaining efficient care processes, supporting interdisciplinary communication, and facilitating family-clinician interaction for decision-making.

Sociotechnical analysis of a neonatal ICU.

Sociotechnical theory has been used to inform the development of computer systems in the complex and dynamic environment of healthcare. The key components of the sociotechnical system are the workers, their practices, their mental models, their interactions, and the tools used in the work process. We conducted a sociotechnical analysis of a neonatal intensive care unit towards the development of decision support for antimicrobial prescribing. We found that the core task was to save the baby in the face of complex and often incomplete information. Organizational climate characteristics were pride in clinical and educational practice. In addition, the structure of work identified interdisciplinary teamwork with some communication breakdown and interruptive work environment. Overall, sociotechnical analysis provided a solid method to understand work environment during the decision support development process.

Frequency and types of alerts for antibiotic prescribing in a neonatal ICU.

Sepsis in neonates is a significant problem that carries with it severe morbidity and mortality. Managing antibiotics in this population is therefore an important issue. We studied clinical alerts currently in place to support antibiotic prescribing in a neonatal intensive care unit in order to ensure that appropriate information is being provided in a way that is consistent with current recommendations. Data were obtained from our alerts tracking database. Alerts were described according to triggering orders and clinician recipients. We found that alerts most commonly associated with antibiotics are providing critical information regarding lab results and patient factors necessary in preventing adverse effects of these drugs. Clinician recipients of alerts are those responsible for entering orders and the information is being provided at the point of care.

Christian practices in urban clinical pastoral education.

This article addresses primarily a connecting link in ministerial formation through the incorporation of certain practices of Christianity within an urban CPE curriculum and the impact on the development of pastoral identity and pastoral practice. Though the focus is identified as Christian the implications and practices are adaptable within all religious and spiritual traditions. The student groups of this urban CPE program represent a wide diversity of cultures and religious traditions and an equal representation of men and women.

Natural Language Processing-Enabled and Conventional Data Capture Methods for Input to Electronic Health Records: A Comparative Usability Study.

BACKGROUND: The process of documentation in electronic health records (EHRs) is known to be time consuming, inefficient, and cumbersome. The use of dictation coupled with manual transcription has become an increasingly common practice. In recent years, natural language processing (NLP)-enabled data capture has become a viable alternative for data entry. It enables the clinician to maintain control of the process and potentially reduce the documentation burden. The question remains how this NLP-enabled workflow will impact EHR usability and whether it can meet the structured data and other EHR requirements while enhancing the user's experience. OBJECTIVE: The objective of this study is evaluate the comparative effectiveness of an NLP-enabled data capture method using dictation and data extraction from transcribed documents (NLP Entry) in terms of documentation time, documentation quality, and usability versus standard EHR keyboard-and-mouse data entry. METHODS: This formative study investigated the results of using 4 combinations of NLP Entry and Standard Entry methods ("protocols") of EHR data capture. We compared a novel dictation-based protocol using MediSapien NLP (NLP-NLP) for structured data capture against a standard structured data capture protocol (Standard-Standard) as well as 2 novel hybrid protocols (NLP-Standard and Standard-NLP). The 31 participants included neurologists, cardiologists, and nephrologists. Participants generated 4 consultation or admission notes using 4 documentation protocols. We recorded the time on task, documentation quality (using the Physician Documentation Quality Instrument, PDQI-9), and usability of the documentation processes. RESULTS: A total of 118 notes were documented across the 3 subject areas. The NLP-NLP protocol required a median of 5.2 minutes per cardiology note, 7.3 minutes per nephrology note, and 8.5 minutes per neurology note compared with 16.9, 20.7, and 21.2 minutes, respectively, using the Standard-Standard protocol and 13.8, 21.3, and 18.7 minutes using the Standard-NLP protocol (1 of 2 hybrid methods). Using 8 out of 9 characteristics measured by the PDQI-9 instrument, the NLP-NLP protocol received a median quality score sum of 24.5; the Standard-Standard protocol received a median sum of 29; and the Standard-NLP protocol received a median sum of 29.5. The mean total score of the usability measure was 36.7 when the participants used the NLP-NLP protocol compared with 30.3 when they used the Standard-Standard protocol. CONCLUSIONS: In this study, the feasibility of an approach to EHR data capture involving the application of NLP to transcribed dictation was demonstrated. This novel dictation-based approach has the potential to reduce the time required for documentation and improve usability while maintaining documentation quality. Future research will evaluate the NLP-based EHR data capture approach in a clinical setting. It is reasonable to assert that EHRs will increasingly use NLP-enabled data entry tools such as MediSapien NLP because they hold promise for enhancing the documentation process and end-user experience.

Initial Usability and Feasibility Evaluation of a Personal Health Record-Based Self-Management System for Older Adults.

INTRODUCTION: Electronic personal health record-based (ePHR-based) self-management systems can improve patient engagement and have an impact on health outcomes. In order to realize the benefits of these systems, there is a need to develop and evaluate heath information technology from the same theoretical underpinnings. METHODS: Using an innovative usability approach based in human-centered distributed information design (HCDID), we tested an ePHR-based falls-prevention self-management system-Self-Assessment via a Personal Health Record (i.e., SAPHeR)-designed using HCDID principles in a laboratory. And we later evaluated SAPHeR's use by community-dwelling older adults at home. RESULTS: The innovative approach used in this study supported the analysis of four components: tasks, users, representations, and functions. Tasks were easily learned and features such as text-associated images facilitated task completion. Task performance times were slow, however user satisfaction was high. Nearly seven out of every ten features desired by design participants were evaluated in our usability testing of the SAPHeR system. The in vivo evaluation suggests that older adults could improve their confidence in performing indoor and outdoor activities after using the SAPHeR system. DISCUSSION/CONCLUSION: We have applied an innovative consumer-usability evaluation. Our approach addresses the limitations of other usability testing methods that do not utilize consistent theoretically based methods for designing and testing technology. We have successfully demonstrated the utility of testing consumer technology use across multiple components (i.e., task, user, representational, functional) to evaluate the usefulness, usability, and satisfaction of an ePHR-based self-management system.

Approaches to workflow analysis in healthcare settings.

Attention to workflow is an important component of a comprehensive approach to designing usable information systems. In healthcare, inattention to workflow is associated with poorly accepted systems and unforeseen effects of use. How best to examine workflow for the purpose of system design is in itself the subject of scientific inquiry. Several disciplines offer approaches to the study of workflow that can be tailored to meet the needs of systems designers in healthcare settings. This paper will describe several methodologies for workflow analysis according to the major schools of thought from which they have been developed. The level of workflow they examine and their theoretical underpinnings will also be described.

Developing Self-Management Tools with Vulnerable Populations for use in Personal Health Information Management Systems.

Vulnerable populations have potential to be significant partners and informants in the development of health information technology. We describe our experience in conducting human-centered participatory design methods with community-dwelling elders in the development of a computer-based falls prevention self-management tool for use in a personal health information management system. Community-dwelling elders contributed significantly to understanding appropriate content and functions; task performance; and graphical representations that should be considered in designing our self-management tool. Design participants should include those who have and have not experienced the clinical condition being considered during the process of system development. Knowledge transfer between system developers and community members about health and personal safety issues can be facilitated through human-centered participatory design methods.

Cognitive analysis of decision support for antibiotic prescribing at the point of ordering in a neonatal intensive care unit.

Computerized decision support systems have been used to help ensure safe medication prescribing. However, the acceptance of these types of decision support has been reported to be low. It has been suggested that decreased acceptance may be due to lack of clinical relevance. Additionally, cognitive fit between the user interface and clinical task may impact the response of clinicians as they interact with the system. In order to better understand clinician responses to such decision support, we used cognitive task analysis methods to evaluate clinical alerts for antibiotic prescribing in a neonatal intensive care unit. Two methods were used: 1) a cognitive walkthrough; and 2) usability testing with a 'think-aloud' protocol. Data were analyzed for impact on cognitive effort according to categories of cognitive distance. We found that responses to alerts may be context specific and that lack of screen cues often increases cognitive effort required to use a system.

Sociotechnical analysis of a neonatal ICU in the context of CPOE.

Computerized provider order entry (CPOE) with decision support is an important tool for addressing preventable medication errors. However, reports of poorly designed systems have shown an increase in adverse events. As part of a project aimed at designing a decision support system for antibiotic prescribing, a sociotechnical approach was used to understand the environment where CPOE is used in a neonatal intensive care unit (NICU). Themes identified included pride in practice, teamwork and collaboration, information integration, and a constantly changing environment.