Nicolette M. McGeorge

The impact of interoperability of electronic health records on ambulatory physician practices: a discrete-event simulation study

BACKGROUND The effect of health information technology (HIT) on efficiency and workload among clinical and nonclinical staff has been debated, with conflicting evidence about whether electronic health records (EHRs) increase or decrease effort. None of this paper to date, however, examines the effect of interoperability quantitatively using discrete event simulation techniques. OBJECTIVE To estimate the impact of EHR systems with various levels of interoperability on day-to-day tasks and operations of ambulatory physician offices. METHODS Interviews and observations were used to collect workflow data from 12 adult primary and specialty practices. A discrete event simulation model was constructed to represent patient flows and clinical and administrative tasks of physicians and staff members. RESULTS High levels of EHR interoperability were associated with reduced time spent by providers on four tasks: preparing lab reports, requesting lab orders, prescribing medications, and writing referrals. The implementation of an EHR was associated with less time spent by administrators but more time spent by physicians, compared with time spent at paper-based practices. In addition, the presence of EHRs and of interoperability did not significantly affect the time usage of registered nurses or the total visit time and waiting time of patients. CONCLUSION This paper suggests that the impact of using HIT on clinical and nonclinical staff work efficiency varies, however, overall it appears to improve time efficiency more for administrators than for physicians and nurses.

Assessment of Innovative Emergency Department Information Displays in a Clinical Simulation Center

The objective of this work was to assess the functional utility of new display concepts for an emergency department information system created using cognitive systems engineering methods, by comparing them to similar displays currently in use. The display concepts were compared to standard displays in a clinical simulation study during which nurse-physician teams performed simulated emergency department tasks. Questionnaires were used to assess the cognitive support provided by the displays, participants’ level of situation awareness, and participants’ workload during the simulated tasks. Participants rated the new displays significantly higher than the control displays in terms of cognitive support. There was no significant difference in workload scores between the display conditions. There was no main effect of display type on situation awareness, but there was a significant interaction; participants using the new displays showed improved situation awareness from the middle to the end of the session. This study demonstrates that cognitive systems engineering methods can be used to create innovative displays that better support emergency medicine tasks, without increasing workload, compared to more standard displays. These methods provide a means to develop emergency department information systems—and more broadly, health information technology—that better support the cognitive needs of healthcare providers.

Usability evaluation of an emergency department information system prototype designed using cognitive systems engineering techniques

This article presents an evaluation of novel display concepts for an emergency department information system (EDIS) designed using cognitive systems engineering methods. EDISs assist emergency medicine staff with tracking patient care and ED resource allocation. Participants performed patient planning and orientation tasks using the EDIS displays and rated the displays ability to support various cognitive performance objectives along with the usability, usefulness, and predicted frequency of use for 18 system components. Mean ratings were positive for cognitive performance support objectives, usability, usefulness, and frequency of use, demonstrating the successful application of design methods to create useful and usable EDIS concepts that provide cognitive support for emergency medicine staff. Nurse and provider roles had significantly different perceptions of the usability and usefulness of certain EDIS components, suggesting that they have different information needs while working.

Usability evaluation and assessment of a novel emergency department IT system developed using a cognitive systems engineering approach

This paper presents the results of a usability evaluation conducted of an electronic Emergency Department information system (EDIS) prototype that was designed using a cognitive system engineering (CSE) approach. Participants were asked to complete tasks using the EDIS prototype, while thinking aloud about their interactions with the displays. Participants also completed subjective assessments of the system that related to 1) cognitive performance support objectives, 2) usability, usefulness, and frequency of system use, and 3) qualitative feedback. Mean scores were calculated for cognitive performance support objectives as well as usability, usefulness, and frequency of use for each display. Mean scores for all cognitive performance support objectives were six or higher. The mean usability score was five or higher, and the mean usefulness score was six or higher. Displays that provided information on individual patient status had the highest scores. Results from this evaluation regarding positive ratings for the cognitive support objectives provide evidence that CSE design methods can be used to understand the goals and objectives of medical work domains.

Better Pairing of Providers and Tools Development of an Emergency Department Information System using Cognitive Engineering Approaches

Health IT systems are often designed without a sufficient understanding of the clinical activities they are intended to support; thus desired benefits in quality of care, safety, and efficiency may not accrue. We present the second part of a multi-phase study which utilizes cognitive systems engineering (CSE) methods to design and test novel user interfaces for a hospital emergency department (ED) information system. Using the work domain analysis results from phase one, display components were developed for a system which can better support work activities and information needs of ED clinicians and staff.

Engineering Better Health IT: Cognitive Systems Engineering of a Novel Emergency Department IT System

Often, health IT systems are designed without a sufficient understanding of the clinical activities they are intended to support; thus desired benefits in quality of care, safety, and efficiency may not accrue. We present the first part of a multi-phase study which utilizes cognitive systems engineering methods to design and test novel user interfaces for a hospital emergency department information system. A work domain analysis was performed and the resultant model was used to identify information requirements and display components for a system which can better support work activities of ED clinicians and staff.

Supporting The Work of Ed Clinicians Assessment Of A Novel Emergency Department Information System In A Clinical Simulation Center

There has been momentum to quickly develop health information technology (IT), but these developments may not result in the expected benefits if the IT is not designed to support caregivers. This research aimed to create an interface for emergency department tracking and control using cognitive systems engineering methods. Comparison of the novel displays with currently in-use display designs in a clinical simulation center demonstrated that the novel displays better support the work of providers without increasing workload.

Characterising the effect of interoperability on healthcare work: a novel framework

Successful design and implementation of interoperable health IT requires an understanding of specific technological capabilities of systems, as well as how these systems impact clinical workflow. Several existing frameworks classify interoperability levels, but none focus on the impact on clinical work, particularly at the task level. A synthesis of existing interoperability frameworks from select interoperability frameworks in the literature about both medical and non-medical systems is presented and a new, 7-level framework in order to characterise the effect of varying levels of interoperability on the users’ work based upon qualitative data collected in a field study of the use of health information exchange in 12 ambulatory practices is proposed. The lowest level describes paper-based tasks completed with no access to electronic information from other institutions; the highest level describes interoperable systems in which data elements from other institutions are integrated into the patients record seamlessly and in a computable format.

Assessing Interaction Strategies for Health IT: An Entropy Based Approach

We proposed new metrics based on information entropy to capture characteristics of screen use and switching among information display screens. These metrics reflect differences in the regularity of the time spent on each screen/display or the number of visits to each screen/display. We also provided simulation and case study to demonstrate the sensitivity and usefulness of the metrics.

Development and Description of a Synthetic, High-Fidelity, Emergency Department Patient Dataset for the Evaluation of Healthcare IT Products

Developing novel interfaces for high-risk situations, such as the Emergency Department, requires a sufficient quantity of detailed patient data to support usability and evaluation activities, yet patient privacy restrictions often prevent the use of actual patient data for these activities. We developed a synthetic dataset to provide a suitable alternative to the use of actual patient data that can be integrated into a variety of research activities. The Emergency Department Information Systems (EDIS) Dataset was developed through close collaboration of experts in Emergency Medicine, Human Factors, and Systems Engineering and provides an ecologically valid set of data for 54 patients, treated in an Emergency Department operating at steady-state, with realistic patient loads and flow. The dataset includes both static and dynamic data for each patient case over a 500-minute time period. A sample application of the dataset is provided to demonstrate how the dataset was used to support the design and evaluation of novel EDIS interface displays and its potential adaptation for future HIT research. This dataset provides a readily adaptable alternative to researchers in need of synthetic patient data to support HIT research and development activities. The EDIS dataset and supporting material are freely available through the University at Buffalo Institutional Repository and can be directly accessed with the URL: hdl.handle.net/10477/75188.