Design and Evaluation of User Centered Electronic Health Records

以用户为中心的电子健康记录的设计和评估

• 批准号: 8785548
• 负责人: ZIA AGHA
• 金额: --
• 依托单位: VA SAN DIEGO HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-10-01 至 2019-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8785548
• 关键词: Accounting; Address; Address; Affect; Affect; Archives; Area; Area; Automation; Automation; Back; Back; Cities; Cities; Clinical; Clinical; Code; Code; Complement; Complement; Computer software; Computer software; Computerized Patient Records; Computerized Patient Records; Computers; Computers; Consultations; Consultations; Data; Data; Data Element; Data Element; Development; Development; Documentation; Documentation; Effectiveness; Effectiveness; Electronic Health Record; Electronic Health Record; Ethnography; Ethnography; Evaluation; Evaluation; Family; Family; Feedback; Feedback; Gap Junctions; Gap Junctions; Goals; Goals; Healthcare Systems; Healthcare Systems; Image; Imagery; Individual; Individual; Information Retrieval; Information Retrieval; Interview; Interview; Knowledge; Knowledge; Laboratories; Laboratories; Language; Language; Manuals; Manuals; Measures; Measures; Methodology; Methodology; Methods; Methods; Metric; Modality; Modality; Motion; Motion; Mus; Mus; Outcome Measure; Outcome Measure; Outpatients; Outpatients; Paste substance; Paste substance; Patient observation; Patient observation; Patients; Patients; Pattern; Pattern; Periodicity; Pharmaceutical Preparations; Pharmaceutical Preparations; Primary Health Care; Primary Health Care; Process; Process; Provider; Provider; Psyche structure; Qualitative Methods; Qualitative Methods; Recording of previous events; Recording of previous events; Research; Research; Resolution; Retrieval; Retrieval; Sampling; Sampling; Sea; Sea; Sequence Alignment; Sequence Alignment; Site; Site; Sodium Chloride; Sodium Chloride; Source; Source; Structure; Structure; System; System; Technology; Technology; Terminology; Terminology; Testing; Testing; Text; Text; Time; Time; Time and Motion Studies; Time and Motion Studies; Trees; Trees; Variant; Variant; Visit; Visit; Visualization; Work; Work; acronyms; acronyms; base; base; care providers; data archive; design; design; imaging study; improved; improved; indexing; indexing; interest; interest; lexical; lexical; next generation; next generation; organizational structure; patient safety; patient safety; point of care; point of care; primary outcome; primary outcome; prototype; prototype; satisfaction; satisfaction; software systems; software systems; structured data; temporal measurement; tool; tool; usability; usability

DESCRIPTION (provided by applicant): To date, there is little quantitative research on how providers use Electronic Health Record (EHR) systems in real clinical settings, and on the methodology and metrics to assess EHR usability: the effectiveness, efficiency, and satisfaction with which users can achieve intended tasks. Such research can identify candidate components for redesign. In particular, documentation of the patient encounter and information retrieval of existing patient data are complementary tasks of the clinical workflow at the point of care. Documentation is often in narrative form stored as unstructured text documents. Providers also retrieve information from previous notes. Lack of EHR automation and poor user interfaces can contribute to the introduction of redundant information into the patient record (eg, information copy/pasted from other areas of the EHR) as well as to inefficient workflows such as the duplicative work that results when clinicians enter orders through structured menus and subsequently manually document these orders in progress notes. In our previous research on time-motion studies in an outpatient setting (PACE study), we found the following: (1) inefficiencies in EHR workflow during the constrained time frame of office consultations. These can be classified as resulting from (a) navigation: providers move across screens to retrieve and then mentally integrate scattered patient information; (b) order entry: driven by nested pull-down menus and other inefficient interfaces, and (c) documentation: notes contain redundant information copy/pasted from earlier notes or other parts of the EHR, duplicative documentation of orders entered, poorly searchable notes, and boilerplate- generating templates. These contribute to information being lost in a "sea of text." (2) The CPRS/VistA Notes function accounts for about half of total EHR activity and is quantifiably a central nexus of activity because providers repeatedly navigate back to Notes for reference (together, Notes and order entry tasks account for 20 ~75% of workflow activity, based on time-at-task, mouse activity and navigation patterns). Therefore, Notes is a promising candidate for redesign. (3) We observed wide variation in providers' EHR workflow and in how they organize information in progress notes, which deserves further study. The proposed project has 3 specific aims: (1) To measure longitudinally the degree of redundancy (primary outcome measure) introduced over time in patient documentation, and to perform baseline content analysis to study variation in how clinicians organize and segment their notes into major sections (eg, SOAP). We will also study lexical and terminology variation across providers. This aim is based on sequence alignment and manual coding of time-indexed archival CPRS/VistA progress notes from two VA sites. Clinician interviews (Stimulated Recall) will provide context for the findings. (2) To quantitatively profile how primary care providers use Notes and the EHR for documentation and information retrieval tasks (eg, which components of the note are newly entered by providers, copy/pasted, or boilerplate? What EHR components do providers access to source existing patient data elements imported in Notes?). This aim is based on existing time-motion data captured for our PACE study at one VA site. (3) To develop and evaluate the ActiveNotes software systems for more usable documentation and order entry system at the point of care. ActiveNotes is a VHA-sponsored project (hi2 initiative). ActiveNotes is an enhanced text editor that uses a technology stack based on parsers to interpret clinicians' input. ActiveNotes uses dynamic layout and hyperlinking to reduce redundant information and optimize documentation and information retrieval tasks of both structured and unstructured EHR data. Formative usability evaluation of prototypes will be iterative and integrated into the Agile development process. Feedback from clinician end-users based on test data, as well as input from other stakeholders, will guide system design decisions.

描述（由申请人提供）： 迄今为止，关于提供者如何在实际临床环境中使用电子健康记录（EHR）系统以及评估EHR可用性的方法和指标：用户可以实现预期任务的有效性，效率和满意度。这样的研究可以识别重新设计的候选组件。特别是，在护理点上，对患者相遇和信息检索的记录是临床工作流程的互补任务。文档通常以叙事形式存储为非结构化的文本文档。提供商还从先前的注释中检索信息。缺乏EHR自动化和差的用户界面可能有助于将冗余信息引入患者记录（例如，信息复制/从EHR领域的其他领域进行粘贴）以及效率低下的工作流程（例如重复的工作），例如临床医生通过结构性菜单输入订单并随后手动记录这些订单时会导致这些订单。在我们先前在门诊环境中进行时间运动研究的研究（PACE研究），我们发现了以下内容：（1）在办公室咨询的约束时间范围内，EHR工作流的效率低下。这些可以分为（a）导航：提供商在屏幕上移动以检索，然后在精神上整合分散的患者信息； （b）订单输入：由嵌套的下拉菜单和其他效率低下的接口驱动，以及（c）文档：注释包含冗余信息复制/从EHR的早期或其他部分粘贴/粘贴，输入订单的重复文档，可搜索的笔记不良，以及锅装板 - 生成板 - 生成模板。这些导致信息在“文本之海”中丢失。 （2）CPRS/VISTA音符功能约占总EHR活动的一半，并且是活动的中心联系，因为提供商反复导航回到注释（一起，注释和订单输入任务，占工作流活动的20 〜75％，基于时间 - 按钮，鼠标活动和导航模式）。因此，注释是重新设计的有前途的候选人。 （3）我们观察到提供者的EHR工作流程以及他们如何组织信息中的信息，这值得进一步研究。拟议的项目具有3个具体目的：（1）纵向测量随着时间的流逝的冗余程度（主要结局指标），并在患者文献中引入了基线含量分析以研究临床医生如何组织和将其笔记分为主要部分的变化（例如，肥皂）。我们还将研究提供者之间的词汇和术语变化。此目的基于来自两个VA站点的时间分数档案CPRS/VISTA进度注释的序列对齐和手动编码。临床医生访谈（刺激召回）将为调查结果提供背景。 （2）定量介绍初级保健提供者如何使用 注释和用于文档和信息检索任务的EHR（例如，该注释的哪些组件由提供商，副本/粘贴或样板新输入？提供商可以访问“源中导入的注释中导入的现有患者数据元素”的EHR组件？）。此目标基于在一个VA站点的PACE研究中捕获的现有时间运动数据。 （3）在护理点开发和评估ARTIVINOTES软件系统，以提供更可用的文档和订单输入系统。 Activenotes是VHA赞助的项目（HI2计划）。 Activenotes是一种增强的文本编辑器，它使用基于解析器的技术堆栈来解释临床医生的意见。 Activenotes使用动态布局和超链接来减少冗余信息，并优化结构化和非结构化EHR数据的文档和信息检索任务。原型的形成性可用性评估将是迭代性的，并将其整合到敏捷开发过程中。基于测试数据的临床医生最终用户的反馈以及其他利益相关者的投入将指导系统设计决策。