Posts Tagged with EHR

posted by adgrooms on June 14, 2019

The ability to retrieve patient information on a computer is an improvement over the paper filing system of years past. Some benefits have yet to be realized but among them are the potential to give patients greater access to their information, doctors greater visibility into patient history, and researchers a wider view to learn more about our health. But this transformation has brought unanticipated pitfalls.

When we talk about user experience (UX) in EHRs, often we talk about how it is hard to navigate. The screens are cluttered, and in general, it takes unnecessary time to accomplish straightforward, common tasks. The real danger is the effect of cognitive overload on the user that in turn produces mental fatigue. Are EHRs detrimental to decision making?

The human brain uses three types of memory:

  • Sensory memory, where incoming information is first received and filtered

  • Working Memory, where critical thinking and problem solving happen

  • Long Term memory, where information is categorized and stored

Physicians have to make many high-risk decisions every day, which requires a high level of thinking and understanding of complex problems. This is primarily done in working memory. However, working memory has limited capacity and different types of information use up working memory's capacity at different rates.

Cognitive load theory shows how different information uses the working memory. Intrinsic cognitive load is the complexity or weight of a task. These are the high stakes decisions that physicians make all day pertaining to patient care. Extraneous cognitive load is determined by the organization of a task or information. This is where poorly designed UX in an EHR can have a detrimental effect on the overall cognitive load. Overly cumbersome systems and processes leave less space for patient care decisions.

How do we improve the situation for physicians? We need to talk about what information is shown and how it is presented in the EHR system. Asking providers to adjust thinking to varied layouts between systems slows workflow and produces cognitive load. A standardized design will make EHR more familiar and consistent, and reduce mental burden.

Borrowing from aviation, EHR developers can design systems with fewer interruptions such as clicking to new windows to find information. The transition between windows causes "blink" attention diversion that can last up to 90 seconds. A well-designed tool will have all of a patient's relevant information available for the physician to view in one window.

One study found that enhanced decision-making support in EHR resulted in less cognitive load and better clinical performance. Enhanced decision-making means providing clear, simple decision pathways based on a standard procedure to information that is needed for a particular patient. It reduces the need for thinking inside the computer system so that the provider can focus on thinking about the patient.

The frustrating thing is that these are not new or unproven ideas. They are simple, well-known, well-tried usability techniques that urgently need to be applied to medical systems. We do not recommend this lightly. Applying a massive user-interface redesign is disruptive. It means yet another round of training and another round of adaptation. There is a high cost to change. The cost to remain the same is much much higher.

posted by adgrooms on June 4, 2019

A recent report in the Annals of Medicine provided an estimate of the institutional cost of physician burnout. The researchers used mathematical data from other recent studies to come up with the conservatively estimated total annual cost of $4.6 billion or $7600 per physician. The study notes that it focused on the cost of replacing physicians and lost income from unfilled positions. When we consider other organizational costs of overburdening physicians, the amount is much higher.

Inefficient systems, which contribute to burn out, are a cost unto themselves. When Physicians are required to spend more than half of their (12 hour) workday in the EHR, their training is not put to best use. The amount of available time for patient care is unnecessarily limited. What would the impact be of reclaiming just one hour for each person? Spent on patient care or spent on self-care, either would lead to a greater benefit to the individual and the organization.

Beyond this, a 12-hour workday is wearing people out to the point of error. Mistakes due to decision fatigue are another hidden cost. At the end of a long day, of course, decisions are not going to be the same quality as those at the start. Minor mistakes lead to costs in unnecessary tests and prescriptions. Major mistakes, in the case of injury, add large costs of lawsuit settlements and legal bills.

Cost-effective solutions to this include:

  • Proper delegation of tasks. e.g. If another staff member can do the task, move it to their queue.
  • Streamlined interfaces.
  • Effective automation.
  • Communication triage.

This study and others have found that a moderate investment per physician can reduce burnout. Considering the extra costs not included in the study, the potential for a large return on investment is very high. Do you see a downside?

posted by adgrooms on May 17, 2019

We have talked about how EHRs can benefit physicians and hospital staff by improving the quality of information and facilitating communication. One of the things severely lacking from EHRs is communication TO the patient about their care. Patients and their families want to be informed about treatments, and providers need patients to participate in their care management.

Currently, information is presented to patients and family verbally across many individuals in the health system - physicians, nurses, assistants, techs, therapists, social workers, dietitians .... There are so many people stopping by the room, talking, writing down notes, scanning medicine and IV bags, evaluating various aspects of the patients status. When family members or a patient advocate staying in the room switches out for a break, they must hand off information to someone else. If the information is not centralized and consolidated, then how accurate will the information be after several hours and possibly several handoffs?

What if EHR companies could develop a patient facing interface with all of this information accessible anytime for the patient. Not like the current clunky patient portal containing just part of the picture, it needs to be a robust, user-friendly interface with the information presented in an easy-to-read and easy-to-navigate format.

This information could include charts, prescription information, timelines, and other notes pertain to treatment and recovery of the patient, utilizing data visualization for easier understanding. Furthermore, you could have a log available to the patient and advocates in the room keeping track of who has stopped by and what action has been performed or what instruction was given at what time. This system could have an option for hospital personnel to scan in, to record their visit. It could include a manual input, to record "civilian" visitors, in case a friend or religious figure stops in. This piece would not impact the patient's health but in the interest of serving the patient, may be a nice benefit.

Patient participation is needed to help physicians and medical staff do their jobs well. An informed patient is better able to participate in their own care.

posted by adgrooms on May 15, 2019

Data visualization can help people quickly understand and use data that would otherwise take a long time to interpret. Word cloud is one visualization technique that communicates the most important words that are relevant to a subject. In a cloud, the size of a word represents its frequency in the source data or its relative importance to the subject.

Word clouds could be used in patient files to give doctors a quick, at-a-glance understanding of a patient's history and condition. The word cloud could pull words from past history and diagnoses to make key points more prominent and guide the doctor in places to start the conversation with the patient. This visual tool could also guide the doctor to look further into the patient file by following themes or exploring minute details.

One study uses a word cloud (they use the term tag cloud) prototype in an EHR to get to know a new patient. They could click on the tag word to learn more about a specific aspect of the patient data. When doctors compare the tag cloud to using a search bar and scrolling through patient data, testers preferred using the tag cloud over the other two options.

The word cloud could also be used as a tool for the doctor to more easily communicate with a patient. Visualizing words in a cloud format could help the patient more readily understand complex diagnosis or instructions to help them manage self-care.

Word clouds work great in a feedback context. Upon discharge, a patient could be given a questionnaire to get an insight into how they felt about their visit. All of the feedback could be periodically be displayed in a word cloud to put into context what patients are saying about their visit to show where improvements could be made.

What other visual tools could benefit health care? What other ways could data be simplified and condensed to help doctors provide better care and patients obtain better understanding?

posted by adgrooms on May 8, 2019

Time is money. With the implementation of EHRs, a doctor's workflow has changed drastically since the time of paper records. Doctors are expected to maintain the same volume of patients while navigating and logging more information than ever in a cumbersome EHR system. Can we quantify the wasting of time among the healthcare front lines?

Before anything happens in the EHR, you have to log in. Logging in takes time. If a doctor isn’t lugging around their own laptop, they will have to log into a computer in the room. In a typical round, they might have 20 patients to see. Gregory Schmidt, M.D. did some research and came up with a 3 minute average login time and some take up to 5 minutes! Even if we consider faster computers, network, and software, a 30 second login time adds up quickly when you calculate for the one million doctors in the United States. And we are not talking about one login at the start of the workday. To protect patient data, doctors are logging in and out all day long.

The problem is worse. Often a provider is using an array of apps in tandem with the EHR, each one with its own username and password. Having to log in to all of these, multiple times a day takes a tremendous amount of time. At a minimum, the hospital should implement single sign-on (SSO), which is a system that consolidates access to all enabled systems into a single username and password. One not so recent study found that moving to SSO could save a hospital over 1400 hours per year across medical and ancillary staff. This resulted in an estimated savings of over $90K per year for each participating hospital.

Even faster, and built upon single sign-on, are physical access tokens. One example of a physical access token is a USB PKI device, such as YubiKey. To use it, the physician would plug the device into the USB port, touch it to confirm their physical presence and be instantly logged in to all SSO enabled software.

Faster still, are scanning technologies, which can log a person in just by their close physical proximity, similar to how modern car keys work. Some even save the state of the desktop as a provider moves from room to room, saving even more time having to locate where they left off.

Evolving fingerprint, eye scan, and voice recognition technology could also be implemented in the future to make logging in even more secure and efficient. The cost of adding these systems would quickly pay for itself in time savings alone, not to mention reduced burnout and increased quality of care.