Jason J. Saleem

Exploring the persistence of paper with the electronic health record

OBJECTIVE Healthcare organizations are increasingly implementing electronic health records (EHRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, employees continue to rely on paper to complete their work. The objective of this study was to explore and understand human-technology integration factors that may be causing employees to rely on paper alternatives to the EHR. METHODS We conducted semi-structured interviews with 20 key-informants in a large Veterans Affairs Medical Center (VAMC), with a fully implemented EHR, to understand the use of paper-based alternatives. Participants included clinicians, administrators, and IT specialists across several service areas in the medical center. RESULTS We found 11 distinct categories of paper-based workarounds to the use of the EHR. Paper use related to the following: (1) efficiency; (2) knowledge/skill/ease of use; (3) memory; (4) sensorimotor preferences; (5) awareness; (6) task specificity; (7) task complexity; (8) data organization; (9) longitudinal data processes; (10) trust; and (11) security. We define each of these and provide examples that demonstrate how these categories promoted paper use in spite of a fully implemented EHR. CONCLUSIONS In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EHR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EHR design and implementation.

Evaluation of an Android-based mhealth system for population surveillance in developing countries

OBJECTIVE In parts of the developing world traditionally modeled healthcare systems do not adequately meet the needs of the populace. This can be due to imbalances in both supply and demand--there may be a lack of sufficient healthcare and the population most at need may be unable or unwilling to take advantage of it. Home-based care has emerged as a possible mechanism to bring healthcare to the populace in a cost-effective, useful manner. This study describes the development, implementation, and evaluation of a mobile device-based system to support such services. MATERIALS AND METHODS Mobile phones were utilized and a structured survey was implemented to be administered by community health workers using Open Data Kit. This system was used to support screening efforts for a population of two million persons in western Kenya. RESULTS Users of the system felt it was easy to use and facilitated their work. The system was also more cost effective than pen and paper alternatives. DISCUSSION This implementation is one of the largest applications of a system utilizing handheld devices for performing clinical care during home visits in a resource-constrained environment. Because the data were immediately available electronically, initial reports could be performed and important trends in data could thus be detected. This allowed adjustments to the programme to be made sooner than might have otherwise been possible. CONCLUSION A viable, cost-effective solution at scale has been developed and implemented for collecting electronic data during household visits in a resource-constrained setting.

Design and Implementation of a Hospital-Based Usability Laboratory: Insights from a Department of Veterans Affairs Laboratory for Health Information Technology

BACKGROUND Although the potential benefits of more usable health information technologies (HIT) are substantial-reduced HIT support costs, increased work efficiency, and improved patient safety--human factors methods to improve usability are rarely employed. The US Department of Veterans Affairs (VA) has emerged as an early leader in establishing usability laboratories to inform the design of HIT, including its electronic health record. Experience with a usability laboratory at a VA Medical Center provides insights on how to design, implement, and leverage usability laboratories in the health care setting. IMPLEMENTATION The VA Health Services Research and Development Service Human-Computer Interaction & Simulation Laboratory emerged as one of the first VA usability laboratories and was intended to provide research-based findings about HIT designs. This laboratory supports rapid prototyping, formal usability testing, and analysis tools to assess existing technologies, alternative designs, and potential future technologies. RESULTS OF IMPLEMENTATION: Although the laboratory has maintained a research focus, it has become increasingly integrated with VA operations, both within the medical center and on a national VA level. With this resource, data-driven recommendations have been provided for the design of HIT applications before and after implementation. CONCLUSION The demand for usability testing of HIT is increasing, and information on how to develop usability laboratories for the health care setting is often needed. This article may assist other health care organizations that want to invest in usability resources to improve HIT. The establishment and utilization of usability laboratories in the health care setting may improve HIT designs and promote safe, high-quality care for patients.

Empirical evaluation of training and a work analysis tool for participatory ergonomics

Abstract A controlled laboratory experiment was performed to test the effects of ergonomics training and the NIOSH lifting equation on the participatory redesign of a simulated manual material handling job. Before performing the job, 16 subjects were given ergonomics training and 16 were instructed on how to use the NIOSH lifting equation for manual lifting tasks. Compared to a control group, subjects who received the ergonomics instruction identified and eliminated more risk factors in the simulated job. While subjects who used the NIOSH lifting equation also identified more risk factors, they did not eliminate any more risk factors than the control group. No additive benefit was found using both the training and the lifting equation over either method alone. Ergonomics training led to better improvements than use of the lifting equation in terms of risk factors identified and eliminated. Implications for use of training and tools in participatory ergonomics approaches are discussed. Relevance to industry This study supports that ergonomics training should be a requisite for any participatory ergonomics approach. Given a fundamental level of ergonomics training, subjects demonstrated that they were better capable of identifying and eliminating risk factors in the job.

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.

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.

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.

Variations in the Usability of Independent Web-Based Personal Health Records

ABSTRACT Previous research on personal health records (PHRs) has focused on applications that are “tethered” to a specific electronic health record (EHR). However, there is a gap in research on the usability of unaffiliated, independent PHRs, as well as research on college-aged PHR users. Therefore, we performed a comparative usability study with 18 college-aged participants on three popular, freely available, independent PHRs. Participants completed the same six tasks in three different PHRs. Dependent variables included task time, mouse movement, mouse clicks, keystrokes, errors, and user satisfaction ratings based on the Computer System Usability Questionnaire (CSUQ). Analysis of variance (ANOVA) was used to determine the significance in the difference of the means for each dependent variable. Results showed statistically significant differences in CSUQ survey categories, errors, and keystrokes. Results supported one of the three PHRs (“System A”) as having better usability than its tested counterparts; participants scored best in System A of all categories of the CSUQ, and used System A with less mouse movement, commission errors, and keystrokes than the other PHRs.

Identifying an Effect of Simulation Role Assignment on Critical Thinking Development in Baccalaureate Nursing Students A Proof of Concept

With an increase in the number of nursing students and the limited number of open clinical positions, high-fidelity patient simulators (HFPS) have become the new norm. Multiple studies have evaluated HFPS effectiveness and several suggest that HFPS does has an effect on critical thinking. This study intends to provide data to support that suggestion. In addition, this study was designed to identify a possible correlation between role assignment and improvements in critical thinking after completion of a HFPS scenario. Analysis revealed that role assignment, for most of the roles, did have a statistically significant effect on the post-simulation critical thinking assessment scores. The relationship between role assignments and HFPS scenario outcomes (such as critical thinking), as well as the nature of the correlation, may help scenario developers better understand how critical thinking improvement can be affected by the involvement of the participant based on the roles assigned to them.

Accessibility, usability, and usefulness of a Web-based clinical decision support tool to enhance provider–patient communication around Self-management TO Prevent (STOP) Stroke

This article reports redesign strategies identified to create a Web-based user-interface for the Self-management TO Prevent (STOP) Stroke Tool. Members of a Stroke Quality Improvement Network (N = 12) viewed a visualization video of a proposed prototype and provided feedback on implementation barriers/facilitators. Stroke-care providers (N = 10) tested the Web-based prototype in think-aloud sessions of simulated clinic visits. Participants’ dialogues were coded into themes. Access to comprehensive information and the automated features/systematized processes were the primary accessibility and usability facilitator themes. The need for training, time to complete the tool, and computer-centric care were identified as possible usability barriers. Patient accountability, reminders for best practice, goal-focused care, and communication/counseling themes indicate that the STOP Stroke Tool supports the paradigm of patient-centered care. The STOP Stroke Tool was found to prompt clinicians on secondary stroke-prevention clinical-practice guidelines, facilitate comprehensive documentation of evidence-based care, and support clinicians in providing patient-centered care through the shared decision-making process that occurred while using the action-planning/goal-setting feature of the tool.