Assessing the Effect of Telemedicine on Physician EHR Work, Cognition, and Process Outcomes (ASPIRE)

评估远程医疗对医生 EHR 工作、认知和流程结果的影响 (ASPIRE)

• 批准号: 10278832
• 负责人: JULIA Rose ADLER-MILSTEIN
• 金额: $ 35.59万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-07-12 至 2025-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10278832
• 关键词: Academic Medical Centers; Address; Ambulatory Care; American; COVID-19; COVID-19 pandemic; California; Caring; Clinical; Clinical assessments; Cognition; Communication; Continuity of Patient Care; Data; Decision Making; Diagnostic; Diagnostic tests; Documentation; Electronic Health Record; Evaluation; Goals; Guidelines; Health; Health system; Healthcare; Institution; Interview; Lead; Length; Measures; Mediating; Modality; Natural experiment; Outcome; Patient Care; Patients; Pattern; Physicians; Process; Proxy; Recording of previous events; Sampling; San Francisco; Structure; Telemedicine; Telephone; Translating; Uncertainty; Universities; Washington; Work; base; care delivery; clinical decision-making; cognitive load; coronavirus disease; data access; design; follow-up; health care delivery; health care service organization; health data; improved; innovation; medical specialties; novel; patient-clinician communication; recruit; virtual

PROJECT SUMMARY The Coronavirus disease 2019 (COVID-19) pandemic dramatically altered healthcare delivery in persistent ways. To adhere to the physical distancing guidelines and to provide continuity of patient care, organizations shifted the primary modality of ambulatory care to telemedicine-based virtual encounters. This transition has altered the structure, management, and delivery of patient care—with large potential changes to patient-provider communication and availability of clinical information. For example, during telemedicine encounters clinicians can no longer conduct physical exams or obtain vitals that inform clinical reasoning and decision making in routine ambulatory evaluation and management (E&M) encounters. In turn, these factors may contribute to clinical uncertainty, and thereby alter how the clinician leverages the electronic health record (EHR). They may need to engage in additional chart review to fill information gaps, enter patient-generated health data, or send more follow-up communications. One or more of these changes serves to intensify EHR-based cognitive load as EHR activities and activity switching increase, both at the encounter level and cumulatively over the course of a workday. In turn, greater EHR-based cognitive load could contribute to suboptimal clinical decisions (e.g., more diagnostic tests or referrals) and more errors (e.g., wrong-patient orders). In the proposed Assessing the Effect of Telemedicine on Physician EHR Work, Cognition, and Process Outcomes (ASPIRE) project, we investigate the primary hypothesis that ambulatory telemedicine encounters in the COVID context are associated with increased EHR-based cognitive load among clinicians, and downstream suboptimal clinical decisions and more frequent errors. We leverage novel, EHR-based audit log data from a 3- year period spanning pre- and COVID-periods (March 2019 – February 2022) to directly measure clinicians' EHR activities in telemedicine and face-to-face encounters at two large academic medical centers (Washington University in St Louis and University of California, San Francisco). Using the COVID-19 pandemic as a natural experiment that dramatically increased ambulatory telemedicine encounters (more than 25-fold at the two health systems), our first aim will characterize the differences in EHR-based activities between face-to-face and telemedicine encounters. We will then construct a derivative measure of EHR activity switches (within and across encounters) as a proxy measure of cognitive load and evaluate the downstream impact of cognitive load on clinical decision making and wrong-patient errors. The findings from these aims will be leveraged in our final “design” aim that uses frontline clinician interviews and a national expert eDelphi process to elicit the EHR-based factors impacting telemedicine encounters and to identify potential design strategies to address associated challenges. The eDelphi process will focus on translating and prioritizing the identified design strategies into pragmatic goals to improve EHR support for telemedicine encounters.

项目摘要 2019年冠状病毒病（Covid-19）大流行以持续的方式改变了医疗保健的分娩。 为了遵守物理疏远准则并提供患者护理的连续性，组织发生了变化 基于远程医疗的虚拟相遇的门诊护理的主要方式。这种过渡改变了 患者护理的结构，管理和交付 - 对患者提供者的潜在变化很大 临床信息的沟通和可用性。例如，在远程医疗期间遇到临床医生 不能再进行身体检查或获得为临床推理和决策提供依据的生命 常规的门诊评估和管理（E＆M）遭遇。反过来，这些因素可能有助于 临床不确定性，从而改变了临床如何利用电子健康记录（EHR）。他们可能 需要进行其他图表审核以填补信息空白，输入患者生成的健康数据或发送 更多后续沟通。这些更改中的一个或多个可以加强基于EHR的认知负荷 随着EHR活动和活动切换的增加，在遭遇水平和整个课程中累积 工作日。反过来，更大的基于EHR的认知负荷可能有助于次优临床决策（例如， 更多的诊断测试或推荐）和更多错误（例如，患者订单）。 在提议评估远程医疗对医师工作，认知和过程的影响中 成果（Aspire）项目，我们调查了一个主要假设 共同环境与临床医生和下游的基于EHR的认知负荷增加有关 次优临床决策和更频繁的错误。我们利用3-- 跨越前和互联的年度（2019年3月至2022年2月）直接衡量临床医生的EHR 在两个大型学术医疗中心（华盛顿）的远程医疗和面对面遭遇的活动 圣路易斯大学和加利福尼亚大学旧金山大学）。将COVID-19大流行作为自然 实验大大增加了门诊远程医疗相遇（在两个健康状况下超过25倍 系统），我们的第一个目标将表征面对面和面对面和面对面的基于EHR的活动的差异 远程医疗相遇。然后，我们将构建EHR活动开关的衍生量度（在 遭遇）作为认知载荷的替代度量，并评估认知负荷对 临床决策和错误患者错误。这些目标的发现将在我们的决赛中得到利用 使用前线临床访谈和国家专家Edelphi流程来引起基于EHR的“设计”目标 影响远程医疗相遇的因素，并确定潜在的设计策略以解决相关的 挑战。 Edelphi流程将重点侧重于将已确定的设计策略转换为 务实的目标是提高对远程医疗相遇的EHR支持。