Nina Kowalczyk

The Role of Cognitive and Learning Theories in Supporting Successful EHR System Implementation Training: A Qualitative Study

Given persistent barriers to effective electronic health record (EHR) system implementation and use, the authors investigated implementation training practices in six organizations reputed to have ambulatory care EHR system implementation “best practices.” Using the lenses of social cognitive and adult learning theories, they explored themes related to EHR implementation training using qualitative data collected through 43 key informant interviews and 6 physician focus groups conducted between February 2009 and December 2010. The authors found consistent evidence that training practices across the six organizations known for exemplary implementations were congruent with the tenets of these theoretical frameworks and highlight seven best practices for training. The authors’ analyses suggest that effective training programs must move beyond technical approaches and incorporate social and cultural factors to make a difference in implementation success. Taking these findings into account may increase the likelihood of successful EHR implementation, thereby helping organizations meet “meaningful use” requirements for EHR systems.

Moving from Good to Great in Ambulatory Electronic Health Record Implementation

&NA; Despite a good general understanding of the need to ensure provider adoption and use of electronic health record (EHR) systems, many implementations fall short of expectations, and little is known about effective approaches in the ambulatory care area. We aimed to comprehensively study and synthesize best practices for ambulatory EHR system implementation in healthcare organizations, emphasizing strategies that maximize physician adoption and use. Following an extensive literature review, we held 47 key informant interviews with representatives of six U.S. healthcare organizations purposively selected based on reported success with ambulatory EHR system implementation. We interviewed both administrative and clinical informants in order to improve our understanding of ambulatory EHR implementation from both perspectives. We found that while all 6 sites studied were reported to have strong EHR implementation practices, we were able to characterize “good” versus “great” approaches across the sites. Specifically, “great” implementations included a key element focused on optimization and improvement over time that helped healthcare organizations support physician adoption and use of the EHR system. The “great” implementation approaches we saw also included explicit considerations of improved data capture and quality of care in their focus on optimization in order to maximize the value of the EHR.

Determining the Rate of Change in Exposure to Ionizing Radiation From CT Scans: A Database Analysis From One Hospital

PURPOSE Cancer risks associated with radiation from CT procedures have recently received increased attention. An important question is whether the combined impact of CT volume and dose reduction strategies has reduced radiation exposure to adult patients undergoing CT examinations. The aim of this study was to determine differences in radiation exposure from 2008 to 2012 to patients receiving CT scans of the abdomen, head, sinus, and lumbar spine at a midwestern academic medical center that implemented dose reduction strategies. METHODS Data were collected from two internal data sets from 2008 to 2012 for general medicine and intensive care unit patients. These data were used to calculate annual CT volume, rate, average effective dose, radiation exposure, and estimated cancer risk. RESULTS A 37% reduction in abdominal CT volume was found from 2008 to 2012. However, no volume reductions were found for CT examinations of the head or lumbar spine, and the decrease in sinus imaging was minimal. Dose reduction strategies resulted in 30% to 52% decreases in radiation exposure for the targeted body areas. The combined reduction in volume and dose per procedure reduced estimated induced cancers by 63%. CONCLUSIONS Exposure to ionizing radiation from these examinations was reduced at one institution because of reduced volumes of procedures and the reduction of each procedures effective dose through new protocols and technologies. Although both the volume reduction and dose reduction strategies contributed to the reduced exposure, it seems that investments in implementing the protocols and new technology had the greatest effect on future cancer risk.

Comparing the Effectiveness of Alerts and Dynamically Annotated Visualizations (DAVs) in Improving Clinical Decision Making

Objective: The aim of this study was to compare the effectiveness of two types of real-time decision support, an interrupting pop-up alert and a noninterrupting dynamically annotated visualization (DAV), in reducing clinically inappropriate diagnostic imaging orders. Background: Alerts in electronic health record software are frequently disregarded due to high false-alarm rates, interruptions, and uncertainty about what triggered the alert. In other settings, providing visualizations and improving understandability of the guidance has been shown to improve overall decision making. Method: Using a between-subject design, we examined the effect of two forms of decision support, alerts and DAVs, on reducing the proportion of inappropriate diagnostic imaging orders for 11 patients in a simulated environment. Nine attending and 11 resident physicians with experience using an electronic health record were randomly assigned to the form of decision support. Secondary measures were self-reported understandability, algorithm transparency, and clinical relevance. Results: Fewer inappropriate diagnostic imaging tests were ordered with DAVs than with alerts (18% vs. 34%, p < .001). The DAV was rated higher for all three secondary measures (p < .001) for all participants. Conclusion: DAVs were more effective than alerts in reducing inappropriate imaging orders and were preferred for all patient scenarios, especially scenarios where guidance was ambiguous or based on inaccurate information. Application: Creating visualizations that are permanently displayed and vary in the strength of their guidance can mitigate the risk of system performance degradation due to incomplete or incorrect data. This interaction paradigm may be applicable for other settings with high false-alarm rates or where there is a need to reduce interruptions during decision making.