Peter Woodbridge

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.

Electronic health information in use: Characteristics that support employee workflow and patient care

The aim of this investigation was to assess helpful and challenging aspects of electronic health information with respect to clinical workflow and identify a set of characteristics that support patient care processes. We conducted 20 semi-structured interviews at a Veterans Affairs Medical Center, with a fully implemented electronic health record (EHR), and elicited positive and negative examples of how information technology (IT) affects the work of healthcare employees. Responses naturally shed light on information characteristics that aid work processes. We performed a secondary analysis on interview data and inductively identified characteristics of electronic information that support healthcare workflow. Participants provided 199 examples of how electronic information affects workflow. Seventeen characteristics emerged along with four primary domains: trustworthy and reliable; ubiquitous; effectively displayed; and adaptable to work demands. Each characteristic may be used to help evaluate health information technology pre- and post-implementation. Results provide several strategies to improve EHR design and implementation to better support healthcare workflow.

Rural Veterans’ Perspectives of Dual Care

The purpose of this study was to develop an in-depth understanding of the barriers and enablers of effective dual care (care obtained from the Veterans Health Administration [VHA] and the private health system) for rural veterans. Telephone interviews of a random sample of 1,006 veterans residing in rural Nebraska were completed in 2010. A high proportion of the rural veterans interviewed reported receiving dual care. The common reasons cited for seeking care outside the VHA (or VA [Veterans Administration]) included having an established relationship with a non-VA provider and distance to the nearest VA medical center. Almost half of the veterans who reported having a personal doctor or nurse reported that this was a non-VA provider. Veterans reported high levels of satisfaction with the quality of care they receive. Ordinal logistic regression models found that veterans who were Medicare beneficiaries, and who rated their health status higher had higher satisfaction with dual care. The reasons cited by the veterans for seeking care at the VHA (quality of VHA care, lower costs of VHA care, entitlement) and veterans perceptions about dual care (confused about where to seek care for different ailments, perceived lack of coordination between VA and non VA providers) were significant predictors of veterans’ satisfaction with dual care. This study will guide policymakers in the VA to design a shared care system that can provide seamless, timely, high quality and veteran centered care.

Transitions in Dual Care for Veterans: Non-Federal Physician Perspectives

Many veterans receive care from both the Veterans Health Administration (VHA) and the non-VHA health system, or dual care. Non-federal physicians practicing in Nebraska were surveyed to examine their perspectives on the organization and delivery of dual care provided to veterans. A paper-based survey was mailed to all 1,287 non-federal primary care physicians (PCPs) and a purposive sample of 765 specialist physicians practising in Nebraska. Rural physicians are more likely to incorporate care coordination practices in their clinical practice, compared to urban physicians. More rural physicians report difficulties in patient transfers, and referrals to the VHA, in prescribing for veteran patients, and in contacting a VHA provider in an emergent situation regarding their veteran patient. More PCPs also report difficulties in referrals to the VHA. However, more rural and primary care physicians follow up with their veteran patients post referral to the VHA. There was agreement among the physicians that the current dual care system needed improvements to provide timely, efficient, coordinated and high quality care to veterans. The specific areas identified for improvement were coordination of care, information sharing, medication management, streamlining of patient transfers, reimbursement for care provided outside the VA, and better delineation and clarity of the boundaries of each system and roles and responsibilities of VA and non-VA providers in the care of veterans.

Paper Use with the Electronic Medical Record: An Important Supplement or Negative Circumvention?

Healthcare organizations are increasingly implementing electronic medical records (EMRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, there are still instances where employees rely on paper to complete their work. The use of paper suggests that parts of the EMR may not be sufficiently designed to support clinicians and their work processes. To understand the use of paper-based alternatives, we conducted 14 key-informant interviews in a large Veterans Affairs Medical Center (VAMC), with a fully implemented EMR. We found nine distinct categories of paper-based workarounds to the use of the EMR. In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EMR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EMR design and implementation.

Communication Enhancement and Best Practices for Co-Managing Dual Care Rural Veteran Patients by VA and Non-VA Providers: A Survey Study

Many rural Veteran patients receive healthcare services from both Veterans Affairs (VA) and non-VA providers. Effective management of dual care Veteran patients to ensure the best clinical outcomes is a VA mission. The previous VA studies indicate that coordination between VA and non-VA providers has been lacking for dual care management of Veteran patients. In this study, we propose that VA proactively shares information with non-VA providers to enhance the communication process and identify the best practices to be carried out by both VA and non-VA providers for better coordination. Structured questionnaires are designed and distributed to VA and non-VA providers to obtain their evaluations on the proposed VA proactive information sharing approaches and the best practice items for dual care management. The non-VA provider respondents largely support the proposed proactive sharing items by VA, with the lowest average score being 3.96 out of a 5.0 scale on one item. In terms of the best practice items on co-managing dual care patients, three out of five items are overall rated higher than 4.0 from both sides. A pair-wise comparison between VA and non-VA perspectives further shows that the difference in average ratings of a proposed item could be significant. For such best practice items, the implementations from both sides may not be most effective.

Healthcare Workers' Perceptions of Information in the Electronic Health Record

Electronic health record (EHR) systems and health information technology (IT) hold unrealized potential for improving the quality, continuity, and safety of medical care; they can also introduce new gaps in care and present unique challenges for healthcare workers. We conducted 14 key informant, semi-structured interviews at a large Veterans Affairs Medical Center and asked healthcare employees why paper use persists despite a fully implemented EHR. In this investigation, we performed a secondary analysis on interview data to identify characteristics of information technology (IT) that are important to support healthcare workflow. As a result of this study, 17 distinct information characteristics emerged; in this document, we provide detail on five characteristics that were often cited as desirable for workflow but insufficiently supported by health IT: 1) customizable, 2) prioritized, 3) trendable, 4) locatable, and 5) accessible. Results from this study reveal key electronic information characteristics for healthcare workflow and have implications for patient safety and future health IT designs.

Performance analysis and improvement of a typical telephone response system of VA hospitals

Purpose – Telephone response system is the frontline of hospital operations. The purpose of this paper is to analyze a representative telephone response system of Veterans Affairs (VA) hospitals, address the existing inefficiency issues such as long call waiting time, and improve system resilience to changes. Design/methodology/approach – Resource sharing schemes are proposed to improve the system performance in answering calls related to appointment booking and medication renewal. Discrete event simulation is adopted to model the current system and the resource sharing schemes. Findings – The resource sharing schemes dramatically improve system performance reflected by the decrease of call waiting time and queue, as well as the extreme high utilization of agents in a key unit. Compared with the less desired alternative of hiring additional employees to mitigate the performance issues, the resource sharing schemes perform at par or even better. Sharing more resource during the peak hours can further balan...