Laura G. Militello

Exploring Barriers and Facilitators to the Use of Computerized Clinical Reminders

OBJECTIVE Evidence-based practices in preventive care and chronic disease management are inconsistently implemented. Computerized clinical reminders (CRs) can improve compliance with these practices in outpatient settings. However, since clinician adherence to CR recommendations is quite variable and declines over time, we conducted observations to determine barriers and facilitators to the effective use of CRs. DESIGN We conducted an observational study of nurses and providers interacting with CRs in outpatient primary care clinics for two days in each of four geographically distributed Veterans Administration (VA) medical centers. MEASUREMENTS Three observers recorded interactions of 35 nurses and 55 physicians and mid-level practitioners with the CRs, which function as part of an electronic medical record. Field notes were typed, coded in a spreadsheet, and then sorted into logical categories. We then integrated findings across observations into meaningful patterns and abstracted the data into themes, such as recurrent strategies. Several of these themes translated directly to barriers and facilitators to effective CR use. RESULTS Optimally using the CR system for its intended purpose was impeded by (1) lack of coordination between nurses and providers; (2) using the reminders while not with the patient, impairing data acquisition and/or implementation of recommended actions; (3) workload; (4) lack of CR flexibility; and (5) poor interface usability. Facilitators included (1) limiting the number of reminders at a site; (2) strategic location of the computer workstations; (3) integration of reminders into workflow; and (4) the ability to document system problems and receive prompt administrator feedback. CONCLUSION We identified barriers that might explain some of the variability in the use of CRs. Although these barriers may be difficult to overcome, some strategies may increase user acceptance and therefore the effectiveness of the CRs. These include explicitly assigning responsibility for each CR to nurses or providers, improving visibility of positive results from CRs in the electronic medical record, creating a feedback mechanism about CR use, and limiting the overall number of CRs.

The science of human factors: separating fact from fiction

Background Interest in human factors has increased across healthcare communities and institutions as the value of human centred design in healthcare becomes increasingly clear. However, as human factors is becoming more prominent, there is growing evidence of confusion about human factors science, both anecdotally and in scientific literature. Some of the misconceptions about human factors may inadvertently create missed opportunities for healthcare improvement. Methods The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities. Results The primary goal of human factors science is to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. As described in this article, human factors also provides insight on when training is likely (or unlikely) to be effective for improving patient safety. Finally, we outline human factors specialty areas that may be particularly relevant for improving healthcare delivery and provide examples to demonstrate their value. Conclusions The human factors concepts presented in this article may foster interdisciplinary collaborations to yield new, sustainable solutions for healthcare quality and patient safety.

Information flow during crisis management: challenges to coordination in the emergency operations center

This paper discusses challenges to coordination in the emergency operations center (EOC). A county-level EOC is made up of representatives from a range of organizations including local government, fire, police, hospital, utility, and Red Cross representatives. These ad hoc teams are tasked with coming together during an emergency to obtain and deliver resources to first responders on the scene of the disaster, as well coordinating transportation of casualties, tracking of fatalities, and establishment of shelters. Two county-level exercises were observed. Themes were identified across the two exercises. Recommendations for better supporting coordination in crisis management are offered.

Defining the methodological challenges and opportunities for an effective science of sociotechnical systems and safety

An important part of the application of sociotechnical systems theory (STS) is the development of methods, tools and techniques to assess human factors and ergonomics workplace requirements. We focus in this paper on describing and evaluating current STS methods for workplace safety, as well as outlining a set of six case studies covering the application of these methods to a range of safety contexts. We also describe an evaluation of the methods in terms of ratings of their ability to address a set of theoretical and practical questions (e.g. the degree to which methods capture static/dynamic aspects of tasks and interactions between system levels). The outcomes from the evaluation highlight a set of gaps relating to the coverage and applicability of current methods for STS and safety (e.g. coverage of external influences on system functioning; method usability). The final sections of the paper describe a set of future challenges, as well as some practical suggestions for tackling these. Practitioner Summary: We provide an up-to-date review of STS methods, a set of case studies illustrating their use and an evaluation of their strengths and weaknesses. The paper concludes with a ‘roadmap’ for future work.

Clinical Reminders: Why Don't they use them?

There are many potential benefits associated with the use of computerized clinical reminders for both health care providers and patients. Clinical reminders are designed to reduce the likelihood that an aspect of care will “fall though the cracks” during a busy exam, ensure that care is well-documented so that the range of health care providers interacting with each patient will have full access to the patient history, and increase standardization across patient exams. While most agree that the concept of clinical reminders is good, recent research indicates that some providers do not use clinical reminders when available (Demakis et al, 2000). This paper describes the qualitative portion of a survey study aimed at exploring the perceived facilitators and barriers to clinical reminder use within Veterans Administration health care facilities.

Redesign of a computerized clinical reminder for colorectal cancer screening: a human-computer interaction evaluation

BackgroundBased on barriers to the use of computerized clinical decision support (CDS) learned in an earlier field study, we prototyped design enhancements to the Veterans Health Administrations (VHAs) colorectal cancer (CRC) screening clinical reminder to compare against the VHAs current CRC reminder.MethodsIn a controlled simulation experiment, 12 primary care providers (PCPs) used prototypes of the current and redesigned CRC screening reminder in a within-subject comparison. Quantitative measurements were based on a usability survey, workload assessment instrument, and workflow integration survey. We also collected qualitative data on both designs.ResultsDesign enhancements to the VHAs existing CRC screening clinical reminder positively impacted aspects of usability and workflow integration but not workload. The qualitative analysis revealed broad support across participants for the design enhancements with specific suggestions for improving the reminder further.ConclusionsThis study demonstrates the value of a human-computer interaction evaluation in informing the redesign of information tools to foster uptake, integration into workflow, and use in clinical practice.

Sources of variation in primary care clinical workflow: implications for the design of cognitive support.

This article identifies sources of variation in clinical workflow and implications for the design and implementation of electronic clinical decision support. Sources of variation in workflow were identified via rapid ethnographic observation, focus groups, and interviews across a total of eight medical centers in both the Veterans Health Administration and academic medical centers nationally regarded as leaders in developing and using clinical decision support. Data were reviewed for types of variability within the social and technical subsystems and the external environment as described in the sociotechnical systems theory. Two researchers independently identified examples of variation and their sources, and then met with each other to discuss them until consensus was reached. Sources of variation were categorized as environmental (clinic staffing and clinic pace), social (perception of health information technology and real-time use with patients), or technical (computer access and information access). Examples of sources of variation within each of the categories are described and discussed in terms of impact on clinical workflow. As technologies are implemented, barriers to use become visible over time as users struggle to adapt workflow and work practices to accommodate new technologies. Each source of variability identified has implications for the effective design and implementation of useful health information technology. Accommodating moderate variability in workflow is anticipated to avoid brittle and inflexible workflow designs, while also avoiding unnecessary complexity for implementers and users.

Collaborative Logistics: Developing a Framework to Evaluate Socio-Technical Issues in Logistic-Based Networks

The concepts of collaborative logistics, logisticsbased networks, focused logistics, and distributed adaptive logistics describe a futuristic approach to logistics planning encompassing automated, adaptive technologies, and proactive human collaboration. Such an approach creates novel challenges for collaboration within socio-technical systems, which encompass the collaborative technologies, the people and machines involved in the act of collaboration, and social context of collaboration. These challenges need to be addressed by theoretical models incorporating multidisciplinary approaches to the study of collaboration. The present paper introduces a framework for collaboration which may inform the design and implementation of collaborative technologies and systems from a socio-technical perspective.

Paper Persistence and Computer-based Workarounds with the Electronic Health Record in Primary Care

With the United States national goal and incentive program to transition from paper to electronic health records (EHRs), healthcare organizations are increasingly implementing EHRs and other related health information technology (IT). However, in institutions which have long adopted these computerized systems, such as the Veterans Health Administration, healthcare workers continue to rely on paper to complete their work. Furthermore, insufficient EHR design also results in computer-based workarounds. Using direct observation with opportunistic interviewing, we investigated the use of paper- and computer-based workarounds to the EHR with a multi-site study of 54 healthcare workers, including primary care providers, nurses, and other healthcare staff. Our analysis revealed several paper- and computer-based workarounds to the VA’s EHR. These workarounds, including clinician-designed information tools, provide evidence for how to enhance the design of the EHR to better support the needs of clinicians.

Conation: Its Historical Roots and Implications for Future Research

This conceptual paper is a review of the literature concerning conation. Although there is no single definition for conation, it has been described in several ways including the mental procedure directed toward action including volition and drive, or as the connection between cognition and affect to action. The historical aspects, applications, and research methods for studying conation are brief but informative. Based on the literature review, the application of conation appears to hold considerable promise, especially within the realm of sociotechnical design/systems.