Presentation
DH2 - Access and Use of Clinical Information in Patient Care: Gaps and Opportunities
DescriptionINTRODUCTION
Electronic Health Record (EHR) usability has been linked to actual and near-miss adverse events (e.g., medical errors) and has emerged as a patient safety threat (Kutney-Lee et al., 2021). A recent study identified a major challenge in the consideration of an enormous amount of patient data, requiring clinicians to have prior knowledge of location and the ability to navigate tools to utilize information (Alami et al., 2022). Previous research found that even when using a well-established EHR, clinicians omitted 32% of lab data from ICU rounds presentations (Artis et al., 2019).
Though considered superior to paper-based processes, usability issues impact clinical burden along with other factors such as interoperability, which limit the sharing of information (Ratwani et al., 2018). Healthcare professionals are faced with the challenges of managing information effectively. As evidenced in a study, nearly 29% of errors in family medicine can be attributed to issues with handling and processing information (Beasley et al., 2011; Dovey et al., 2002). Extraneous patient information in each medical chart is a major source of frustration for physicians. Excessive information in a chart, known as "note bloat," can impair comprehension and lead to errors (Sinsky et al., 2016; Zulman et al., 2016).
The goal of this study was to identify areas of challenge experienced by clinicians in the use of clinical decision support tools. We used qualitative interviews to obtain a rich description of challenges and effective strategies for information management during patient care to ultimately inform the design of a decision support tool.
METHODS
The study was approved by the Institutional Review Board (IRB).
Participants
We recruited from a network of team members with no compensation provided.
Materials
The interview guide was developed through a draft and iteration process. The guide included questions on demographics, work tasks, challenges, lived experience examples, and recommendations for decision support tool design. Example questions included:
1. If you had more time for each patient, what would you do with that time?
2. What are the tasks and activities that are the most challenges and why? Please respond to this question with consideration for people, technologies, and the environment as factors in making your work easy and/or difficult.
3. Please think of a challenging situation/event/incident in your work in which information [fell through the cracks] and the outcome was either positive or negative. Could this situation have been mitigated or resolved with a well-designed decision support tool? What might it look like?
Procedure
The interviews were conducted over Zoom or a recorded phone call, following obtaining participant consent. The interviews lasted for an hour with one or two researchers present and debrief was conducted following conclusion.
RESULTS
Demographics
We interviewed 5 participants, including 4 male physicians (specialties of primary, ambulatory, pediatric, and emergency department care) and 1 female primary care nurse. All participants were White, with age ranging from 31 to 62 years. Participant experience ranged from 4 to 41 years of experience. All served populations that include are racially and ethnically diverse and have a lower socio-economic status patient residing in rural areas. Three had an informatics background.
Patient Care Challenges
Using thematic analysis, we identified patient care challenges that participants reported experiencing in their day-to-day practice. All participants reported that the limited time allocated per patient makes it difficult to gather and manage information, thus, leading to delays in care. In addition, we identified the following challenges:
• Gathering information on unusual cases is time-consuming and managing co-morbidities adds to challenge.
• Charting at the end of the day results in difficulties with memory and recall, which can perpetuate gaps in the electronic health record (EHR) over time.
• Difficulties in gathering information from multiple resources, maintaining patient records over time, tracking evolving guidelines, and considering cultural knowledge and sensitivity when communicating about illness and treatment.
• Following up with diagnostic tests, especially in current scenarios where patients receive test results before time permits for physician interpretation.
• Managing medication dosing, especially for pediatric populations, and navigating novice avoidance or difficulties in having difficult conversations or performing uncomfortable procedures.
Informed by these findings, we developed a set of design recommendations. Each recommendation is traceable to the data.
Recommendations
Based on the findings, it is evident that physicians are facing several challenges in their day-to-day practice which hinders the quality of patient care. The teams identified several design recommendations, informed by the experience and feedback from physicians, gaps identified, and are aimed at streamlining the information gathering and management process, improving charting and documentation, and enhancing communication and follow-up.
DISCUSSION
This study highlights the importance of continued characterization of remaining and new clinician challenges as the healthcare system transforms. The recommendations from the study participants suggest a need for a timeline or temporal and longitudinal view of each patient's information to provide a comprehensive and integrated view of their health history which support clinician planning and mitigate patient ‘surprises’. As evidenced in studies, patient timelines and detailed view facilitates the identification and exploration of trends and details, and reduce the chances of clinicians overlooking information (Gill et al., 2010; Rostamzadeh et al., 2021). Integration of multiple common co-morbidities into a single view can support the pulling of patient story together to help healthcare providers make informed decisions about a patient's care. However, this could potentially create room for error.
To further improve efficiency, study participants recommended the use of digital post-it notes and checklists for common conditions as a memory aid that can help providers quickly access relevant information. Gawande, a researcher and surgeon, discusses the science of improving healthcare and proposes that predictable processes (well-honed checklists) can be used to prevent the most uncertain of errors (Nasir, 2010). A reduction in clicks and screens to access relevant information is also recommended for efficiency. A post deployment user feedback from provider-group interviews identified “too many clicks” as a contributing factor to increased burden (Mann et al., 2019). Participants emphasized on the importance of decision support for costly diagnostic tests and the need for clear predictive indices of lab values and indicators of prevalence and incidence to mitigate overuse by novices, inform level of consideration and mitigate nonessential medical interventions.
Additionally, the ability to perform various calculations that are difficult to do mentally can help reduced cognitive load of the decision-making process of patient care.
Electronic Health Record (EHR) usability has been linked to actual and near-miss adverse events (e.g., medical errors) and has emerged as a patient safety threat (Kutney-Lee et al., 2021). A recent study identified a major challenge in the consideration of an enormous amount of patient data, requiring clinicians to have prior knowledge of location and the ability to navigate tools to utilize information (Alami et al., 2022). Previous research found that even when using a well-established EHR, clinicians omitted 32% of lab data from ICU rounds presentations (Artis et al., 2019).
Though considered superior to paper-based processes, usability issues impact clinical burden along with other factors such as interoperability, which limit the sharing of information (Ratwani et al., 2018). Healthcare professionals are faced with the challenges of managing information effectively. As evidenced in a study, nearly 29% of errors in family medicine can be attributed to issues with handling and processing information (Beasley et al., 2011; Dovey et al., 2002). Extraneous patient information in each medical chart is a major source of frustration for physicians. Excessive information in a chart, known as "note bloat," can impair comprehension and lead to errors (Sinsky et al., 2016; Zulman et al., 2016).
The goal of this study was to identify areas of challenge experienced by clinicians in the use of clinical decision support tools. We used qualitative interviews to obtain a rich description of challenges and effective strategies for information management during patient care to ultimately inform the design of a decision support tool.
METHODS
The study was approved by the Institutional Review Board (IRB).
Participants
We recruited from a network of team members with no compensation provided.
Materials
The interview guide was developed through a draft and iteration process. The guide included questions on demographics, work tasks, challenges, lived experience examples, and recommendations for decision support tool design. Example questions included:
1. If you had more time for each patient, what would you do with that time?
2. What are the tasks and activities that are the most challenges and why? Please respond to this question with consideration for people, technologies, and the environment as factors in making your work easy and/or difficult.
3. Please think of a challenging situation/event/incident in your work in which information [fell through the cracks] and the outcome was either positive or negative. Could this situation have been mitigated or resolved with a well-designed decision support tool? What might it look like?
Procedure
The interviews were conducted over Zoom or a recorded phone call, following obtaining participant consent. The interviews lasted for an hour with one or two researchers present and debrief was conducted following conclusion.
RESULTS
Demographics
We interviewed 5 participants, including 4 male physicians (specialties of primary, ambulatory, pediatric, and emergency department care) and 1 female primary care nurse. All participants were White, with age ranging from 31 to 62 years. Participant experience ranged from 4 to 41 years of experience. All served populations that include are racially and ethnically diverse and have a lower socio-economic status patient residing in rural areas. Three had an informatics background.
Patient Care Challenges
Using thematic analysis, we identified patient care challenges that participants reported experiencing in their day-to-day practice. All participants reported that the limited time allocated per patient makes it difficult to gather and manage information, thus, leading to delays in care. In addition, we identified the following challenges:
• Gathering information on unusual cases is time-consuming and managing co-morbidities adds to challenge.
• Charting at the end of the day results in difficulties with memory and recall, which can perpetuate gaps in the electronic health record (EHR) over time.
• Difficulties in gathering information from multiple resources, maintaining patient records over time, tracking evolving guidelines, and considering cultural knowledge and sensitivity when communicating about illness and treatment.
• Following up with diagnostic tests, especially in current scenarios where patients receive test results before time permits for physician interpretation.
• Managing medication dosing, especially for pediatric populations, and navigating novice avoidance or difficulties in having difficult conversations or performing uncomfortable procedures.
Informed by these findings, we developed a set of design recommendations. Each recommendation is traceable to the data.
Recommendations
Based on the findings, it is evident that physicians are facing several challenges in their day-to-day practice which hinders the quality of patient care. The teams identified several design recommendations, informed by the experience and feedback from physicians, gaps identified, and are aimed at streamlining the information gathering and management process, improving charting and documentation, and enhancing communication and follow-up.
DISCUSSION
This study highlights the importance of continued characterization of remaining and new clinician challenges as the healthcare system transforms. The recommendations from the study participants suggest a need for a timeline or temporal and longitudinal view of each patient's information to provide a comprehensive and integrated view of their health history which support clinician planning and mitigate patient ‘surprises’. As evidenced in studies, patient timelines and detailed view facilitates the identification and exploration of trends and details, and reduce the chances of clinicians overlooking information (Gill et al., 2010; Rostamzadeh et al., 2021). Integration of multiple common co-morbidities into a single view can support the pulling of patient story together to help healthcare providers make informed decisions about a patient's care. However, this could potentially create room for error.
To further improve efficiency, study participants recommended the use of digital post-it notes and checklists for common conditions as a memory aid that can help providers quickly access relevant information. Gawande, a researcher and surgeon, discusses the science of improving healthcare and proposes that predictable processes (well-honed checklists) can be used to prevent the most uncertain of errors (Nasir, 2010). A reduction in clicks and screens to access relevant information is also recommended for efficiency. A post deployment user feedback from provider-group interviews identified “too many clicks” as a contributing factor to increased burden (Mann et al., 2019). Participants emphasized on the importance of decision support for costly diagnostic tests and the need for clear predictive indices of lab values and indicators of prevalence and incidence to mitigate overuse by novices, inform level of consideration and mitigate nonessential medical interventions.
Additionally, the ability to perform various calculations that are difficult to do mentally can help reduced cognitive load of the decision-making process of patient care.
Event Type
Poster Presentation
TimeTuesday, March 264:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives