Understanding Barriers and Facilitators to Living Kidney Donation Within a Sociotechnical Systems Framework.

The objective of this study was to investigate factors influencing one's decision to become a live kidney donor under the framework of sociotechnical systems, by expanding the focus to include larger organizational influences and technological considerations. Semi-structured interviews were conducted with live kidney donors who donated through University of Louisville Health, Trager Transplant Center, a mid-scale transplant program, in the years 2017 through 2019. The interview transcripts were analyzed for barriers and facilitators to live kidney donation within a sociotechnical system. The most salient facilitators included: having an informative, caring, and available care team; the absence of any negative external pressure toward donating; donating to a family or friend; and the ability to take extra time off work for recovery. The most recurrent barriers included: short/medium-term (<1 year) negative health impacts because of donation; the need to make minor lifestyle changes (e.g., less alcohol consumption) after donation; and mental health deterioration stemming from the donation process. The sociotechnical systems framework promotes a balanced system comprised of social, technical, and environmental subsystems. Assessing the facilitators and barriers from the sociotechnical system perspective revealed the importance of and opportunities for developing strategies to promote integration of technical subsystem, such as social media apps and interactive AI platforms, with social and environmental subsystems to enable facilitators and reduce barriers effectively.

Automated Text Messaging During COVID-19: Patient Feedback to Increase Adoption.

Automated text messaging interventions can effectively improve self-care and were used to support the U.S. Veterans Health Administration's (VHA) public health outreach during the COVID pandemic. Currently, significant gaps exist in knowledge about VHA patients' texting protocol preferences that may impact user receptivity, engagement, and effectiveness. This study qualitatively evaluated patient suggestions to improve two VHA Covid-related texting interventions and preferences for future text message protocols. We reviewed cross-sectional type-written survey responses from patients receiving either the "Coronavirus Precautions" or the "Coping During COVID" multi-week text protocols. Two team members independently and inductively coded all responses allowing for an upward abstraction of qualitative data. Nine hundred five patients (72.8% male) responded to the open-response item questions targeted by this research. An item that sought feedback to improve protocol acceptability generated thirteen distinct descriptive categories (inter-rater reliability 83.5%). Codable feedback showed, for example, that patients desired to manipulate message frequency and to have a more sophisticated interaction with messages. Patients' suggestions for future automated text messaging protocols yielded nine distinct topic areas. Patients offered suggestions that may impact receptivity and engagement of future automated text message protocols, particularly as they relate to outreach during a public health crisis. In addition, patients offered specific topics they would like to see in future text message protocols. We discuss how the findings can be used to increase engagement in current and post-pandemic public health interventions.

Development and cross-sectional evaluation of a text message protocol to support mental health well-being.

Coping with stressors related to the coronavirus disease (COVID) pandemic has caused major mental health challenges. Text message interventions are identified as helpful for promoting health behavior self-management. Drawing from cognitive-behavioral theory (CBT), U.S. Veterans Health Administration staff developed a 20-week automated text messaging protocol called "Coping During COVID" to support veterans' self-care during the pandemic. This project evaluated attitudes about and perceived helpfulness of the protocol among 651 veterans. A cross-sectional evaluation quantitatively assessed COVID-related stressors as well as reported use, acceptability, attitudes, and perceived helpfulness of the protocol via a self-administered online questionnaire. Open-ended questions assessed perceived helpfulness/unhelpfulness of the protocol. Of the 651 veterans (22% of those enrolled in the protocol) who responded to the survey, 73.1% were male and 88.5% were 50 years or over. Ninety percent found the protocol messages helpful and about half endorsed various additional benefits, including feeling better, being more educated about coping behaviors, and being better able to focus on positive thoughts. Qualitative feedback was overwhelmingly positive. For example, veterans stated that the protocol "was like having a personal coach giving hints and tips to cope with the boredom every day," that it "gave me reminders of skills I was not using. It helped me focus on the positives," and brought relief from "many hopeless and sad thoughts … the messages from Annie have been a Godsend to me." Overall results suggested that the Coping During COVID text messaging protocol successfully supported the majority of respondents' self-care efforts during the COVID pandemic. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Veteran and Staff Experience from a Pilot Program of Health Care System-Distributed Wearable Devices and Data Sharing.

OBJECTIVE: The growing trend to use wearable devices to track activity and health data has the potential to positively impact the patient experience with their health care at home and with their care team. As part of a pilot program, the U.S. Department of Veterans Affairs (VA) distributed Fitbits to Veterans through four VA medical centers. Our objective was to assess the program from both Veterans' and clinicians' viewpoints. Specifically, we aimed to understand barriers to Fitbit setup and use for Veterans, including syncing devices with a VA mobile application (app) to share data, and assess the perceived value of the device functions and ability to share information from the Fitbit with their care team. In addition, we explored the clinicians' perspective, including how they expected to use the patient-generated health data (PGHD). METHODS: We performed semi-structured interviews with 26 Veterans and 16 VA clinicians to assess the program. Responses to each question were summarized in order of frequency of occurrence across participants and audited by an independent analyst for accuracy. RESULTS: Our findings reveal that despite setup challenges, there is support for the use of Fitbits to engage Veterans and help manage their health. Clinicians believed there were benefits for having Veterans use the Fitbits and expected to use the PGHD in a variety of ways as part of the Veterans' care plans, including monitoring progress toward health behavior goals. Veterans were overwhelmingly enthusiastic about using the Fitbits; this enthusiasm seems to extend beyond the 3 month "novelty period." CONCLUSION: The pilot program for distributing Fitbits to Veterans appears to be successful from both Veterans' and clinicians' perspectives and suggests that expanded use of wearable devices should be considered. Future studies will need to carefully consider how to incorporate the PGHD into the electronic health record and clinical workflow.

Clinician Perspectives on Unmet Needs for Mobile Technology Among Hospitalists: Workflow Analysis Based on Semistructured Interviews.

BACKGROUND: The hospitalist workday is cognitively demanding and dominated by activities away from patients' bedsides. Although mobile technologies are offered as solutions, clinicians report lower expectations of mobile technology after actual use. OBJECTIVE: The purpose of this study is to better understand opportunities for integrating mobile technology and apps into hospitalists' workflows. We aim to identify difficult tasks and contextual factors that introduce inefficiencies and characterize hospitalists' perspectives on mobile technology and apps. METHODS: We conducted a workflow analysis based on semistructured interviews. At a Midwestern US medical center, we recruited physicians and nurse practitioners from hospitalist and inpatient teaching teams and internal medicine residents. Interviews focused on tasks perceived as frequent, redundant, and difficult. Additionally, participants were asked to describe opportunities for mobile technology interventions. We analyzed contributing factors, impacted workflows, and mobile app ideas. RESULTS: Over 3 months, we interviewed 12 hospitalists. Participants collectively identified chart reviews, orders, and documentation as the most frequent, redundant, and difficult tasks. Based on those tasks, the intake, discharge, and rounding workflows were characterized as difficult and inefficient. The difficulty was associated with a lack of access to electronic health records at the bedside. Contributing factors for inefficiencies were poor usability and inconsistent availability of health information technology combined with organizational policies. Participants thought mobile apps designed to improve team communications would be most beneficial. Based on our analysis, mobile apps focused on data entry and presentation supporting specific tasks should also be prioritized. CONCLUSIONS: Based on our results, there are prioritized opportunities for mobile technology to decrease difficulty and increase the efficiency of hospitalists' workflows. Mobile technology and task-specific mobile apps with enhanced usability could decrease overreliance on hospitalists' memory and fragmentation of clinical tasks across locations. This study informs the design and implementation processes of future health information technologies to improve continuity in hospital-based medicine.

Veterans' response to an automated text messaging protocol during the COVID-19 pandemic.

The US Department of Veterans Affairs (VA) is using an automated short message service application named "Annie" as part of its coronavirus disease 2019 (COVID-19) response with a protocol for coronavirus precautions, which can help the veteran monitor symptoms and can advise the veteran when to contact his or her VA care team or a nurse triage line. We surveyed 1134 veterans on their use of the Annie application and coronavirus precautions protocol. Survey results support what is likely a substantial resource savings for the VA, as well as non-VA community healthcare. Moreover, the majority of veterans reported at least 1 positive sentiment (felt more connected to VA, confident, or educated and/or felt less anxious) by receiving the protocol messages. The findings from this study have implications for other healthcare systems to help manage a patient population during the coronavirus pandemic.

Provider Preference in Exam Room Layout Design and Computing.

BACKGROUND: The introduction of the electronic health record (EHR) has had a significant impact on provider-patient interactions, particularly revolving around patient-centeredness. More research is needed to understand the provider perspective of this interaction. OBJECTIVES: Our objective was to obtain provider feedback on a new exam room design compared with the one already in use with respect to the computing layout, which included a wall-mounted monitor for ease of (re)-positioning. An additional objective was to understand elements of exam room design and computing that were highly valued. METHODS: Semistructured interviews were conducted with 28 providers from several health care organizations. Interviews were audio recorded and transcribed for analysis. We used an inductive coding approach to abstract recurrent themes from the data. RESULTS: Our analysis revealed several themes organized around exam room layout, exam room computing, and provider workflow. We report frequency of occurrence of the coded data for computer accessories, computing usefulness, computer mobility, documentation habits, form factor, layout preference, patient interaction, screen sharing, and work habits. CONCLUSION: Providers in our study preferred exam room design to promote flexibility, mobility, and body orientation directed toward the patient. Providers also expressed the need for exam room design to support varying work habits and preferences, including whether to share the computer screen or not.

Field Investigation of Ambulatory Clinic Exam Room Design with respect to Computing Devices: A Pilot Study.

The Department of Veterans Affairs (VA) has developed a new exam room design standard that is intended to facilitate a greater degree of patient centeredness. This new design includes a wall-mounted monitor on an armature system and a moveable table workspace. To date, however, this design has not been formally evaluated in a field setting. We conducted observations and interviews with primary care providers and their patients from three locations within the Phoenix VA Health Care System, in a pilot study comparing the new exam room design standard with the older legacy exam rooms. When using the new exam room layout, providers spent a greater proportion of time focused on the patient, spent more time in screen-sharing activities with the patient, and had a higher degree of self-reported situation awareness. However, the legacy exam rooms were perceived as better facilitating workflow integration. Provider and patient debrief interviews were supportive of the new exam room design. Overall, our field study results suggest that the new exam room design does contribute to a greater degree of patient centeredness, though more thorough evaluations are required to support these preliminary results.

A cognitive systems engineering design approach to improve the usability of electronic order forms for medical consultation.

BACKGROUND: During medical referrals, communication barriers between referring and consulting outpatient clinics delay patients' access to health care. One notable opportunity for reducing these barriers is improved usefulness and usability of electronic medical consultation order forms. The cognitive systems engineering (CSE) design approach focuses on supporting humans in managing cognitive complexity in sociotechnical systems. Cognitive complexity includes communication, decision-making, problem solving, and planning. OBJECTIVE: The objective of this research was to implement a CSE design approach to develop a template that supports the cognitive needs of referring clinicians and improves referral communication. METHODS: We conducted interviews and observations with primary care providers and specialists at two major tertiary, urban medical facilities. Using qualitative analysis, we identified cognitive requirements and design guidelines. Next, we designed user interface (UI) prototypes and compared their usability with that of a currently implemented UI at a major Midwestern medical facility. RESULTS: Physicians' cognitive challenges were summarized in four cognitive requirements and 13 design guidelines. As a result, two UI prototypes were developed to support order template search and completion. To compare UIs, 30 clinicians (referrers) participated in a consultation ordering simulation complemented with the think-aloud elicitation method. Oral comments about the UIs were coded for both content and valence (i.e., positive, neutral, or negative). Across 619 comments, the odds ratio for the UI prototype to elicit higher-valenced comments than the implemented UI was 13.5 (95% CI = [9.2, 19.8]), p < .001. CONCLUSION: This study reinforced the significance of applying a CSE design approach to inform the design of health information technology. In addition, knowledge elicitation methods enabled identification of physicians' cognitive requirements and challenges when completing electronic medical consultation orders. The resultant knowledge was used to derive design guidelines and UI prototypes that were more useful and usable for referring physicians. Our results support the implementation of a CSE design approach for electronic medical consultation orders.

The effect of role assignment in high fidelity patient simulation on nursing students: An experimental research study.

BACKGROUND: Previous studies have evaluated the effectiveness of high fidelity patient simulators (HFPS) on nursing training; however, a gap exists on the effects of role assignment on critical thinking, self-efficacy, and situation awareness skills in team-based simulation scenarios. OBJECTIVES: This study aims to determine if role assignment and the involvement level related to the roles yields significant effects and differences in critical thinking, situation awareness and self-efficacy scores in team-based high-fidelity simulation scenarios. DESIGN: A single factorial design with five levels and random assignment was utilized. SETTING: A public university-sponsored simulation center in the United States of America. PARTICIPANTS: A convenience sample of 69 junior-level baccalaureate nursing students was recruited for participation. METHODS: Participants were randomly assigned one of five possible roles and completed pre-simulation critical thinking and self-efficacy assessments prior to the simulation beginning. Playing within their assigned roles, participants experienced post-partum hemorrhaging scenario using an HFPS. After completing the simulation, participants completed a situation awareness assessment and a post-simulation critical thinking and self-efficacy assessment. RESULTS: Role assignment was found to have a statistically significant effect on critical thinking skills and a statistically significant difference in various areas of self-efficacy was also noted. However, no statistical significance in situation awareness abilities was found. CONCLUSIONS: Results support the notion that certain roles required the participant to be more involved with the simulation scenario, which may have yielded higher critical thinking and self-efficacy scores than roles that required a lesser level of involvement.

Ten factors to consider when developing usability scenarios and tasks for health information technology.

The quality of usability testing is highly dependent upon the associated usability scenarios. To promote usability testing as part of electronic health record (EHR) certification, the Office of the National Coordinator (ONC) for Health Information Technology requires that vendors test specific capabilities of EHRs with clinical end-users and report their usability testing process - including the test scenarios used - along with the results. The ONC outlines basic expectations for usability testing, but there is little guidance in usability texts or scientific literature on how to develop usability scenarios for healthcare applications. The objective of this article is to outline key factors to consider when developing usability scenarios and tasks to evaluate computer-interface based health information technologies. To achieve this goal, we draw upon a decade of our experience conducting usability tests with a variety of healthcare applications and a wide range of end-users, to include healthcare professionals as well as patients. We discuss 10 key factors that influence scenario development: objectives of usability testing; roles of end-user(s); target performance goals; evaluation time constraints; clinical focus; fidelity; scenario-related bias and confounders; embedded probes; minimize risks to end-users; and healthcare related outcome measures. For each factor, we present an illustrative example. This article is intended to aid usability researchers and practitioners in their efforts to advance health information technologies. The article provides broad guidance on usability scenario development and can be applied to a wide range of clinical information systems and applications.

Investigating the need for clinicians to use tablet computers with a newly envisioned electronic health record.

OBJECTIVE: The Veterans Health Administration (VHA) has deployed a large number of tablet computers in the last several years. However, little is known about how clinicians may use these devices with a newly planned Web-based electronic health record (EHR), as well as other clinical tools. The objective of this study was to understand the types of use that can be expected of tablet computers versus desktops. METHODS: Semi-structured interviews were conducted with 24 clinicians at a Veterans Health Administration (VHA) Medical Center. RESULTS: An inductive qualitative analysis resulted in findings organized around recurrent themes of: (1) Barriers, (2) Facilitators, (3) Current Use, (4) Anticipated Use, (5) Patient Interaction, and (6) Connection. CONCLUSIONS: Our study generated several recommendations for the use of tablet computers with new health information technology tools being developed. Continuous connectivity for the mobile device is essential to avoid interruptions and clinician frustration. Also, making a physical keyboard available as an option for the tablet was a clear desire from the clinicians. Larger tablets (e.g., regular size iPad as compared to an iPad mini) were preferred. Being able to use secure messaging tools with the tablet computer was another consistent finding. Finally, more simplicity is needed for accessing patient data on mobile devices, while balancing the important need for adequate security.

Performance, workload, and usability in a multiscreen, multi-device, information-rich environment.

Potential benefits of multiscreen and multiple device environments were assessed using three different computing environments. A single factor, within-subject study was conducted with 18 engineering students in a laboratory experiment. Three levels for the computing environment factor included one with a desktop computer with a single monitor (control, condition A); one with a desktop with dual monitors, as well as a single tablet computer (condition B); and one with a desktop with a single monitor, as well as two tablet computers (condition C). There was no statistically significant difference in efficiency or workload when completing scenarios for the three computing environments. However, a dual monitor desktop with a single tablet computer (B) was the ideal computing environment for the information-rich engineering problem given to participants, supported by significantly fewer errors compared to condition C and significantly higher usability ratings compared to conditions A and C. A single desktop monitor with two tablet computers (C) did not provide any advantage compared to a single desktop monitor (A).

Ambulatory Clinic Exam Room Design with respect to Computing Devices: A Laboratory Simulation Study.

BACKGROUND: Challenges persist regarding how to integrate computing effectively into the exam room, while maintaining patient-centered care. PURPOSE: Our objective was to evaluate a new exam room design with respect to the computing layout, which included a wall-mounted monitor for ease of (re)-positioning. METHODS: In a lab-based experiment, 28 providers used prototypes of the new and older "legacy" outpatient exam room layouts in a within-subject comparison using simulated patient encounters. We measured efficiency, errors, workload, patient-centeredness (proportion of time the provider was focused on the patient), amount of screen sharing with the patient, workflow integration, and provider situation awareness. RESULTS: There were no statistically significant differences between the exam room layouts for efficiency, errors, or time spent focused on the patient. However, when using the new layout providers spent 75% more time in screen sharing activities with the patient, had 31% lower workload, and gave higher ratings for situation awareness (14%) and workflow integration (17%). CONCLUSIONS: Providers seemed to be unwilling to compromise their focus on the patient when the computer was in a fixed position in the corner of the room and, as a result, experienced greater workload, lower situation awareness, and poorer workflow integration when using the old "legacy" layout. A thoughtful design of the exam room with respect to the computing may positively impact providers' workload, situation awareness, time spent in screen sharing activities, and workflow integration.

Evaluating a Modular Decision Support Application For Colorectal Cancer Screening.

BACKGROUND: There is a need for health information technology evaluation that goes beyond randomized controlled trials to include consideration of usability, cognition, feedback from representative users, and impact on efficiency, data quality, and clinical workflow. This article presents an evaluation illustrating one approach to this need using the Decision-Centered Design framework. OBJECTIVE: To evaluate, through a Decision-Centered Design framework, the ability of the Screening and Surveillance App to support primary care clinicians in tracking and managing colorectal cancer testing. METHODS: We leveraged two evaluation formats, online and in-person, to obtain feedback from a range primary care clinicians and obtain comparative data. Both the online and in-person evaluations used mock patient data to simulate challenging patient scenarios. Primary care clinicians responded to a series of colorectal cancer-related questions about each patient and made recommendations for screening. We collected data on performance, perceived workload, and usability. Key elements of Decision-Centered Design include evaluation in the context of realistic, challenging scenarios and measures designed to explore impact on cognitive performance. RESULTS: Comparison of means revealed increases in accuracy, efficiency, and usability and decreases in perceived mental effort and workload when using the Screening and Surveillance App. CONCLUSION: The results speak to the benefits of using the Decision-Centered Design approach in the analysis, design, and evaluation of Health Information Technology. Furthermore, the Screening and Surveillance App shows promise for filling decision support gaps in current electronic health records.

Pilot evaluation of a method to assess prescribers' information processing of medication alerts.

BACKGROUND: Prescribers commonly receive alerts during medication ordering. Prescribers work in a complex, time-pressured environment; to enhance the effectiveness of safety alerts, the effort needed to cognitively process these alerts should be minimized. Methods to evaluate the extent to which computerized alerts support prescribers' information processing are lacking. OBJECTIVE: To develop a methodological protocol to assess the extent to which alerts support prescribers' information processing at-a-glance; specifically, the incorporation of information into their working memory. We hypothesized that the method would be feasible and that we would be able to detect a significant difference in prescribers' information processing with a revised alert display that incorporates warning design guidelines compared to the original alert display. METHODS: A counterbalanced, within-subject study was conducted with 20 prescribers in a human-computer interaction laboratory. We tested a single alert that was displayed in two different ways. Prescribers were informed that an alert would appear for 10s. After the alert was shown, a white screen was displayed, and prescribers were asked to verbally describe what they saw; indicate how many total warnings; and describe anything else they remembered about the alert. We measured information processing via the accuracy of prescribers' free recall and their ability to identify that three warning messages were present. Two analysts independently evaluated participants' responses against a comprehensive catalog of alert elements and then discussed discrepancies until reaching consensus. RESULTS: This feasibility study demonstrated that the method seemed to be effective for evaluating prescribers' information processing of medication alert displays. With this method, we were able to detect significant differences in prescribers' recall of alert information. The proportion of total data elements that prescribers were able to accurately recall was significantly greater for the revised versus original alert display (p=0.006). With the revised display, more prescribers accurately reported that three warnings were shown (p=0.002). CONCLUSIONS: The methodological protocol was feasible for evaluating the alert display and yielded important findings on prescribers' information processing. Study methods supplement traditional usability evaluation methods and may be useful for evaluating information processing of other healthcare technologies.

Designing Colorectal Cancer Screening Decision Support: A Cognitive Engineering Enterprise.

Adoption of clinical decision support has been limited. Important barriers include an emphasis on algorithmic approaches to decision support that do not align well with clinical work flow and human decision strategies, and the expense and challenge of developing, implementing, and refining decision support features in existing electronic health records (EHRs). We applied decision-centered design to create a modular software application to support physicians in managing and tracking colorectal cancer screening. Using decision-centered design facilitates a thorough understanding of cognitive support requirements from an end user perspective as a foundation for design. In this project, we used an iterative design process, including ethnographic observation and cognitive task analysis, to move from an initial design concept to a working modular software application called the Screening & Surveillance App. The beta version is tailored to work with the Veterans Health Administration's EHR Computerized Patient Record System (CPRS). Primary care providers using the beta version Screening & Surveillance App more accurately answered questions about patients and found relevant information more quickly compared to those using CPRS alone. Primary care providers also reported reduced mental effort and rated the Screening & Surveillance App positively for usability.

Understanding barriers and facilitators to the use of Clinical Information Systems for intensive care units and Anesthesia Record Keeping: A rapid ethnography.

OBJECTIVE: This study evaluated the current use of commercial-off-the-shelf Clinical Information Systems (CIS) for intensive care units (ICUs) and Anesthesia Record Keeping (ARK) for operating rooms and post-anesthesia care recovery settings at three Veterans Affairs Medical Centers (VAMCs). Clinicians and administrative staff use these applications at bedside workstations, in operating rooms, at nursing stations, in physician's rooms, and in other various settings. The intention of a CIS or an ARK system is to facilitate creation of electronic records of data, assessments, and procedures from multiple medical devices. The US Department of Veterans Affairs (VA) Office of the Chief of Nursing Informatics sought to understand usage barriers and facilitators to optimize these systems in the future. Therefore, a human factors study was carried out to observe the CIS and ARK systems in use at three VAMCs in order to identify best practices and suggested improvements to currently implemented CIS and ARK systems. METHODS: We conducted a rapid ethnographic study of clinical end-users interacting with the CIS and ARK systems in the critical care and anesthesia care areas in each of three geographically distributed VAMCs. Two observers recorded interactions and/or interview responses from 88 CIS and ARK end-users. We coded and sorted into logical categories field notes from 69 shadowed participants. The team transcribed and combined data from key informant interviews with 19 additional participants with the observation data. We then integrated findings across observations into meaningful patterns and abstracted the data into themes, which translated directly to barriers to effective adoption and optimization of the CIS and ARK systems. RESULTS: Effective optimization of the CIS and ARK systems was impeded by: (1) integration issues with other software systems; (2) poor usability; (3) software challenges; (4) hardware challenges; (5) training concerns; (6) unclear roles and lack of coordination among stakeholders; and (7) insufficient technical support. Many of these barriers are multi-faceted and have associated sub-barriers, which are described in detail along with relevant quotes from participants. In addition, regionalized purchases of different CIS and ARK systems, as opposed to enterprise level purchases, contributed to some of the identified barriers. Facilitators to system use included (1) automation and (2) a dedicated facility-level CIS-ARK Coordinator. CONCLUSIONS: We identified barriers that explain some of the challenges with the optimization of the CIS and ARK commercial systems across the Veterans Health Administration (VHA). To help address these barriers, and evolve them into facilitators, we categorized report findings as (1) interface and system-level changes that vendors or VA healthcare systems can implement; (2) implementation factors under VA control and not under VA control; and (3) factors that may be used to inform future application purchases. We outline several recommendations for improved adoption of CIS and ARK systems and further recommend that human factors engineering and usability requirements become an integral part of VA health information technology (HIT) application procurement, customization, and implementation in order to help eliminate or mitigate some of the barriers of use identified in this study. Human factors engineering methods can be utilized to apply a user-centered approach to application requirements specification, application evaluation, system integration, and application implementation.

Design and Evaluation of an Electronic Override Mechanism for Medication Alerts to Facilitate Communication Between Prescribers and Pharmacists.

BACKGROUND: Computerized medication alerts can often be bypassed by entering an override rationale, but prescribers' override reasons are frequently ambiguous to pharmacists who review orders. OBJECTIVE: To develop and evaluate a new override mechanism for adverse reaction and drug-drug interaction alerts. We hypothesized that the new mechanism would improve usability for prescribers and increase the clinical appropriateness of override reasons. METHODS: A counterbalanced, crossover study was conducted with 20 prescribers in a simulated prescribing environment. We modified the override mechanism timing, navigation, and text entry. Instead of free-text entry, the new mechanism presented prescribers with a predefined set of override reasons. We assessed usability (learnability, perceived efficiency, and usability errors) and used a priori criteria to evaluate the clinical appropriateness of override reasons entered. RESULTS: Prescribers rated the new mechanism as more efficient (Wilcoxon signed-rank test, P = 0.032). When first using the new design, 5 prescribers had difficulty finding the new mechanism, and 3 interpreted the navigation to mean that the alert could not be overridden. The number of appropriate override reasons significantly increased with the new mechanism compared with the original mechanism (median change of 3.0; interquartile range = 3.0; P < 0.0001). CONCLUSIONS: When prescribers were given a menu-based choice for override reasons, clinical appropriateness of these reasons significantly improved. Further enhancements are necessary, but this study is an important first step toward a more standardized menu of override choices. Findings may be used to improve communication through e-prescribing systems between prescribers and pharmacists.