Aviv Shachak

Primary care physicians' use of an electronic medical record system: a cognitive task analysis.

OBJECTIVETo describe physicians’ patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient–doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular.DESIGNCognitive task analysis using semi-structured interviews and field observations.PARTICIPANTSTwenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel.RESULTSThe comprehensiveness, organization, and readability of data in the EMR system reduced physicians’ need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient’s chart. EMR use interfered with patient–doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians’ communication skills also helped.CONCLUSIONSThere is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians’ offices and by enhancing physicians’ computer and communication skills.

Structured versus unstructured tagging: a case study

Purpose – This paper seeks to describe and discuss a tagging experiment involving images related to Israeli and Jewish cultural heritage. The aim of this experiment was to compare freely assigned tags with values (free text) assigned to predefined metadata elements.Design/methodology/approach – Two groups of participants were asked to provide tags for 12 images. The first group of participants was asked to assign descriptive tags to the images without guidance (unstructured tagging), while the second group was asked to provide free‐text values to predefined metadata elements (structured tagging).Findings – The results show that on the one hand structured tagging provides guidance to the users, but on the other hand different interpretations of the meaning of the elements may worsen the tagging quality instead of improving it. In addition, unstructured tagging allows for a wider range of tags.Research limitations/implications – The recommendation is to experiment with a system where the users provide both ...

The impact of an evidence-based medicine educational intervention on primary care physicians: a qualitative study.

BackgroundAttitudes and barriers to implementing EBM have been examined extensively, but scant evidence exists regarding the impact of EBM teaching on primary care physicians’ point of care behavior.ObjectiveGaining insight into behavioral and attitudinal changes of facilitators and participants during a multifaceted EBM educational intervention.Design, setting, and participantsA qualitative study on primary care physicians and facilitators from a large HMO selected from the intervention arm of a parallel controlled trial using purposeful sampling. We conducted focus groups with 13 facilitators and 17 physicians and semi-structured interviews with 10 facilitators and 11 physicians.ResultsBoth facilitators and participants believed EBM enhanced the quality of their practice. The intervention affected attitudes and knowledge, but had little impact on physicians’ ability to utilize pre-appraised resources at the point of care. Using EBM resources during consultation was perceived to be a complex task and impractical in a busy setting. Conversely, a positive impact on using medication databases was noted. Medication databases were perceived as easy to use during consultations in which the benefits outweighed the barriers. The intervention prompted physicians to write down clinical questions more frequently and to search for answers at home.ConclusionsThis study underlines the need not only to enhance EBM skills, but also to improve the ease of use of EBM resources at the point of care. Tasks should be simplified by tailoring evidence-based information retrieval systems to the busy clinical schedule. Participants’ recommendations to establish an HMO decision support service should be considered.

Electronic health records in the age of social networks and global telecommunications.

ON AUGUST 20, 2009, THE US GOVERNMENT ANnounced

Computers in the clinical encounter: a scoping review and thematic analysis

1.2 billion in new grants as part of the American Recovery and Reinvestment Act to promote “meaningful use” of electronic health records (EHRs) by all individuals in 2011, and to support the development of mechanisms for information sharing through EHRs in the United States. This investment is happening at a time of massive reduction in the costs of data collection, exchange, and storage; of convergence of technologies; and massive public adoption of smart telephones and online social media. In this Commentary, we propose some components for consideration during the development of the EHR network that will emerge in the United States. This proposal recognizes that these important trends create a unique opportunity for the emergence of a national system of interconnected EHRs in the United States and for a rethinking of how EHRs are constructed and used, and to promote a truly people-centered health care system. This proposed framework includes 7 components based on resources and knowledge that exist today, and may contribute to current efforts to provide the public with access to tools that meet the public’s needs and expectations.

Immunological cross-reaction between bud and bark proteins of dormant deciduous trees

OBJECTIVE Patient-clinician communication has been associated with increased patient satisfaction, trust in the clinician, adherence to prescribed therapy, and various health outcomes. The impact of health information technology (HIT) on the clinical encounter in general and patient-clinician communication in particular is a growing concern. The purpose of this study was to review the current literature on HIT use during the clinical encounter to update best practices and inform the continuous development of HIT policies and educational interventions. METHODS We conducted a literature search of four databases. After removing duplicates, reviewing titles and abstracts, performing a full-text review, and snowballing from references and citations, 51 articles were included in the analysis. We employed a qualitative thematic analysis to compare and contrast the findings across studies. RESULTS Our analysis revealed that the use of HIT affects consultations in complex ways, impacting eye contact and gaze, information sharing, building relationships, and pauses in the conversation. Whether these impacts are positive or negative largely depends on the combination of consultation room layout, patient and clinician styles of interaction with HIT as well as each other, and the strategies and techniques employed by clinicians to integrate HIT into consultations. DISCUSSION The in-depth insights into the impact of HIT on the clinical encounter, especially the strategies and techniques employed by clinicians to adapt to using HIT in consultations, can inform policies, educational interventions, and research. CONCLUSION In contrast to the common negative views of HIT, it affects the clinical encounter in multiple ways. By applying identified strategies and best practices, HIT can support patient-clinician interactions rather than interfering with them.

End-user support for primary care electronic medical records: a qualitative case study of users’ needs, expectations, and realities

Dormancy-related inflorescence bud protein IBP32 of Pistacia vera (pistachio) was detected in the bark of pistachio showing immunological cross-reaction with bud and bark proteins of several phylogenetically unrelated species. In the bark of P. atlantica, a 32-kDa protein was detected. Other positive immunological reactions were obtained with a protein of approximately 62 kDa derived from the bark of peach and with a 34-kDa protein from bud and bark of poplar (Populus euphratica). The latter protein was also detected by antibodies against the bark storage protein (BSP) of Pop. canadensis. Pistachio IBPs did not cross-react with these antibodies. A protein from grape bud of approximately 6 kDa reacted weakly with pistachio IBP antibodies. A weak positive reaction was obtained with a 46-kDa protein of saltbush. There was no cross-reaction between pistachio IBPs and either bud proteins of peach, bark proteins of grape, or bud and bark proteins of plum and apricot. It is still unknown whether the proteins showing immunological cross-reaction are structurally and functionally related, and if they are affected by the same environmental and physiological factors. Some answers may lie in the relationship between IBPs and BSPs.

Patient-Physician Interactions and Electronic Health Records

Support is considered an important factor for realizing the benefits of health information technology, but there is a dearth of research on the topic of support, especially in primary care. We conducted a qualitative multiple case study of four family health teams and one family health organization in Ontario, Canada in an attempt to gain insight into users’ expectations and needs, and the realities of end-user support for primary care electronic medical records. Data were collected by semi-structured interviews, document review, and observation of training sessions. The analysis highlights the important role of on-site information technology staff and super-users in liaising with various stakeholders to solve technical problems and providing hardware and functional (how to) support; the local development of data support practices to ensure consistent documentation; and the gaps that exist in users’ and support personnel’s understanding of each other’s work processes.

What do electronic health record vendors reveal about their products: an analysis of vendor websites.

Patient-Physician Interactions and Electronic Health Records To the Editor In their recent Viewpoint, Drs White and Danis1 discussed using the electronic health record (EHR) to enhance patient-physician interactions. Whereas others have argued that the EHR can hinder patient-physician communication,2 the authors hold a more optimistic view that expanded uses (such as inviting patients to participate in EHR viewing during the clinical encounter) are untapped tools for patient activation. We share the optimism of White and Danis for health care information technology. During an era of technology innovation and adoption in all aspects of daily life, patients as well as medical professionals are, in general, becoming increasingly familiar with computer use during the clinical encounter. Current EHR systems, however, can be awkward to use, and there is a lack of standardized data structure for true integration of patient data across different EHR platforms.3 These issues are technical and will likely be overcome through innovations in EHR technology, allowing expanded EHR use to further enhance patient care. Additionally, there is a growing repertoire of technologybased tools for patient activation that can complement the EHR. The relatively nascent web-based patient portals allow patients to securely log in and access their personal health information. The portal pulls data from the patient’s EHR and can support items such as screening reminders and patient-physician messaging. One study showed that patient portals in conjunction with an EHR may improve patient engagement.4 Health care–focused social networks also offer a platform for patient activation. Patients can post questions online about their health condition. Physicians registered with the network can then post answers, which can be peer reviewed by other registered physicians. As medical students, we believe proper EHR usage instruction during medical education is important. Patientphysician communication is a part of the standard curriculum at most medical schools. For example, during our preclinical years, we learned a patient-centered model of patient interviewing. These interviews can serve as opportunities for students to practice using the EHR in a way to enhance the interaction. Appropriate use of the EHR to enhance patient activation can thus be taught concurrently with patient communication.2,5 Ultimately, EHR education in medical school will train physicians to become skilled users of this tool.

User Manuals for a Primary Care Electronic Medical Record System: A Mixed-Methods Study of User- and Vendor-Generated Documents

Background Purchasing electronic health records (EHRs) typically follows a process in which potential adopters actively seek information, compare alternatives, and form attitudes towards the product. A potential source of information on EHRs that can be used in the process is vendor websites. It is unclear how much product information is presented on EHR vendor websites or the extent of its value during EHR purchasing decisions. Objective To explore what features of EHR systems are presented by vendors in Ontario, Canada, on their websites, and the persuasive means they use to market such systems; to compare the online information available about primary care EHR systems with that about hospital EHR systems, and with data compiled by OntarioMD, a regional certifying agency. Methods A list of EHR systems available in Ontario was created. The contents of vendor websites were analyzed. A template for data collection and organization was developed and used to collect and organize information on the vendor, website content, and EHR features. First, we mapped information on system features to categories based on a framework from the Institute of Medicine (IOM). Second, we used a grounded theory–like approach to explore information for building consumer confidence in the vendor and product, and the various persuasive strategies employed on vendor websites. All data were first coded by one researcher. A peer reviewer independently analyzed a randomly chosen subset of the websites (10 of 21; 48%) and provided feedback towards a unified coding scheme. All data were then re-coded and categorized into themes. Finally, we compared information from vendor websites and data gathered by OntarioMD. Results Vendors provided little specific product information on their websites. Only two of five acute care EHR websites (40%) and nine of 16 websites for primary care systems (56%) featured seven or all eight of the IOM components. Several vendor websites included system interface demonstrations: screenshots (six websites), public videos or slideshows (four websites), or for registered viewers only (three websites). Persuasive means used by vendors included testimonials on 14/21 (67%) websites, and directional language. Except for one free system, trial EHR versions were not available. OntarioMD provided more comprehensive information about primary care systems than the vendors’ websites. Of 14 points of comparison, only the inclusion of templates and bilingual interfaces were fully represented in both data sources. For all other categories, the vendor websites were less complete than the OntarioMD site. Conclusions EHR vendor websites employ various persuasive means, but lack product-specific information and do not provide options for trying systems on a limited basis. This may impede the ability of potential adopters to form perceptions and compare various offerings. Both vendors and clients could benefit from greater transparency and more specific product information on the Web. Trial Registration N/A