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CDA 09-024 – HSR&D Study

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CDA 09-024
Circumventing Health IT: Identifying Patient Safety Risks
Jason J. Saleem PhD MS
Richard L. Roudebush VA Medical Center, Indianapolis, IN
Indianapolis, IN
Funding Period: October 2009 - September 2014

BACKGROUND/RATIONALE:
This CDA-2 research program focuses on identifying and mitigating human-technology integration factors (e.g., computer usability and human-computer interaction issues) at the electronic health record (EHR) level that may be causing clinicians to rely on circumventing the intended use of CPRS and related health information technology (IT). In Years 1-4, substantial progress has been made on the research objective to "Identify workarounds to CPRS and related health IT that have potential to result in patient harm." Computerized consults was the first application of "VA Health IT" chosen for study as (1) it is an important problem of interest to VHA, (2) the current way consults are managed involves a lot of manual / paper-based processes, with no easy way to track pending consults, and (3) delays in processing consults and in specialty care may adversely impact patient safety. The second application of VA Health IT for this CDA was computerized clinical documentation (i.e., progress notes). This is also an important problem of interest considering many providers refuse to use the EHR during a patient encounter, making documentation demands difficult to meet. This also has patient safety implications since information from a patient encounter is often documented in the electronic health record (EHR) hours or even days after the actual encounter. Taking a broader view of the electronic health record, interviews with key VA leaders were performed in Year 3 to understand their views on what is needed for the next generation EHR. These results were published in Year 4.

OBJECTIVE(S):
The consultation request process between primary care and specialty services often contains paper-based components that may be inefficient and difficult to track. Barriers to consult management may impact delivery of quality medical care. In addition, clinical documentation demands challenge providers in a time-constrained environment. Many providers prefer not to use the EHR while with the patient. Circumventing documentation in the EHR during the patient encounter creates potential gaps in documentation. This CDA-2 investigates current challenges to computerized consults, progress notes, and other VA health IT, using a sociotechnical perspective. This research also integrates the perspective from key VA leaders on what is needed for the next-generation VA EHR.

METHODS:
For the investigation of the computerized consults, ethnographic observations and semi-structured interviews were conducted in nine different specialty clinics and three primary care clinics in a large, tertiary VA Medical Center. Observational field notes were typed and interviews were transcribed; these data were coded for barriers, including workarounds and communication breakdowns. A retrospective analysis was performed of 'electronic error and enhancement requests' (E3Rs) related to the consult package in the VA's electronic health record (EHR) submitted over a 5-year period (2005-2009). E3Rs from this national query were reviewed and categorized based on the nature of the enhancement requests. The same observation and interview methods have been employed to study clinical documentation in primary care and specialty care clinics. In Year 3, interviews were performed with 14 key VA leaders to understand their views on what is needed for the next generation EHR in terms of cognitive support, information synthesis and sense-making, customization, teamwork, interoperability, data availability, interface usability, and management of information.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Study findings provide a platform for VA informatics tools for consultation management and clinical documentation that better support clinical workflow and the delivery of quality medical care. These data are complemented by a broader perspective from interviews with VA leaders on what is need for the next-generation VA EHR. Poor human-computer interface design and lack of integration into clinical workflow lead to the use of workarounds and impact the use of VA informatics systems, potentially placing patient safety at risk. Results from this research program are anticipated to inform future redesign of VA informatics tools to reduce the risk of patient harm. This research program will position our program to provide human-computer interaction and usability research evidence to inform the VA's future development of clinical decision support and health IT development and implementation.

PUBLICATIONS:

Journal Articles

  1. Russ AL, Zillich AJ, Melton BL, Russell SA, Chen S, Spina JR, Weiner M, Johnson EG, Daggy JK, McManus MS, Hawsey JM, Puleo AG, Doebbeling BN, Saleem JJ. Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation. Journal of the American Medical Informatics Association : JAMIA. 2014 Oct 1; 21(e2):e287-96.
  2. Flanagan M, Arbuckle N, Saleem JJ, Militello LG, Haggstrom DA, Doebbeling BN. Development of a workflow integration survey (WIS) for implementing computerized clinical decision support. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2013 Jun 26; 2011:427-34.
  3. Flanagan ME, Saleem JJ, Millitello LG, Russ AL, Doebbeling BN. Paper- and computer-based workarounds to electronic health record use at three benchmark institutions. Journal of the American Medical Informatics Association : JAMIA. 2013 Jun 1; 20(e1):e59-66.
  4. Saleem JJ, Flanagan ME, Wilck NR, Demetriades J, Doebbeling BN. The next-generation electronic health record: perspectives of key leaders from the US Department of Veterans Affairs. Journal of the American Medical Informatics Association : JAMIA. 2013 Jun 1; 20(e1):e175-7.
  5. Saleem JJ, Adams S, Frankel RM, Doebbeling BN, Patterson ES. Efficiency strategies for facilitating computerized clinical documentation in ambulatory care. Studies in health technology and informatics. 2013 Jan 1; 192:13-7.
  6. Russ AL, Weiner M, Russell SA, Baker DA, Fahner WJ, Saleem JJ. Design and implementation of a hospital-based usability laboratory: insights from a Department of Veterans Affairs laboratory for health information technology. Joint Commission Journal on Quality and Patient Safety. 2012 Dec 1; 38(12):531-40.
  7. Rajput ZA, Mbugua S, Amadi D, Chepngeno V, Saleem JJ, Anokwa Y, Hartung C, Borriello G, Mamlin BW, Ndege SK, Were MC. Evaluation of an Android-based mHealth system for population surveillance in developing countries. Journal of the American Medical Informatics Association : JAMIA. 2012 Jul 1; 19(4):655-9.
  8. Russ AL, Zillich AJ, McManus MS, Doebbeling BN, Saleem JJ. Prescribers' interactions with medication alerts at the point of prescribing: A multi-method, in situ investigation of the human-computer interaction. International journal of medical informatics. 2012 Apr 1; 81(4):232-43.
  9. Chumbler NR, Haggstrom D, Saleem JJ. Implementation of health information technology in Veterans Health Administration to support transformational change: telehealth and personal health records. Medical care. 2011 Dec 1; 49 Suppl:S36-42.
  10. Haggstrom DA, Saleem JJ, Russ AL, Jones J, Russell SA, Chumbler NR. Lessons learned from usability testing of the VA's personal health record. Journal of the American Medical Informatics Association : JAMIA. 2011 Dec 1; 18 Suppl 1:i13-7.
  11. Saleem JJ, Haggstrom DA, Militello LG, Flanagan M, Kiess CL, Arbuckle N, Doebbeling BN. Redesign of a computerized clinical reminder for colorectal cancer screening: a human-computer interaction evaluation. BMC medical informatics and decision making. 2011 Nov 29; 11:74.
  12. Saleem JJ, Russ AL, Neddo A, Blades PT, Doebbeling BN, Foresman BH. Paper persistence, workarounds, and communication breakdowns in computerized consultation management. International journal of medical informatics. 2011 Jul 1; 80(7):466-79.
  13. Saleem JJ, Patterson ES, Russ AL, Wears RL. The need for a broader view of human factors in the surgical domain. Archives of surgery (Chicago, Ill. : 1960). 2011 May 1; 146(5):631-2.
  14. Wess ML, Saleem JJ, Tsevat L, Luckhaupt SE, Johnson JA, Wise RE, Kopke JE, Eckman MH. Usability of an Atrial Fibrillation Anticoagulation Decision-Support Tool. Journal of primary care & community health. 2011 Apr 1; 2(2):100-106.
  15. Russ AL, Saleem JJ, Justice CF, Woodward-Hagg H, Woodbridge PA, Doebbeling BN. Electronic health information in use: Characteristics that support employee workflow and patient care. Health Informatics Journal. 2010 Dec 1; 16(4):287-305.
  16. Russ AL, Baker DA, Fahner WJ, Milligan BS, Cox L, Hagg HK, Saleem JJ. A Rapid Usability Evaluation (RUE) Method for Health Information Technology. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2010 Nov 13; 2010:702-6.
  17. Wu S, Lehto MR, Yih Y, Saleem JJ, Doebbeling BN. Impact of Clinical Reminder Redesign on Physicians’ Priority Decisions. Applied clinical informatics. 2010 Nov 1; 2(4):466-485.
  18. Nazi KM, Hogan TP, Wagner TH, McInnes DK, Smith BM, Haggstrom D, Chumbler NR, Gifford AL, Charters KG, Saleem JJ, Weingardt KR, Fischetti LF, Weaver FM. Embracing a health services research perspective on personal health records: lessons learned from the VA My HealtheVet system. Journal of general internal medicine. 2010 Jan 1; 25 Suppl 1:62-7.
  19. Haggstrom DA, Saleem JJ, Militello LG, Arbuckle N, Flanagan M, Doebbeling BN. Examining the relationship between clinical decision support and performance measurement. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2009 Nov 14; 2009:223-7.
  20. Russ AL, Zillich AJ, McManus MS, Doebbeling BN, Saleem JJ. A human factors investigation of medication alerts: barriers to prescriber decision-making and clinical workflow. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2009 Nov 14; 2009:548-52.
  21. Saleem JJ, Militello LG, Arbuckle N, Flanagan M, Haggstrom DA, Linder JA, Doebbeling BN. Provider perceptions of colorectal cancer screening clinical decision support at three benchmark institutions. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2009 Nov 14; 2009:558-62.
Journal Other

  1. Chen S, Melton BL, Saleem JJ, Johnson E, Weiner M, Russell S, McManus MS, Doebbeling BN, Russ AL. The Effect of Redesigned Computerized Drug-Drug Interaction Alerts on Medication Errors and Prescribing Efficiency. [Abstract]. Value in health : the journal of the International Society for Pharmacoecon. 2013 May 1; 16(3):A13.
  2. Russ AL, Weiner M, Saleem JJ, Wears RL. When 'technically preventable' alerts occur, the design--not the prescriber--has failed. [Letter to the Editor]. Journal of the American Medical Informatics Association : JAMIA. 2012 Nov 1; 19(6):1119; author reply 1119-20.
  3. Saleem JJ, Russ AL, Zillich AJ. Usability Testing to Refine a Pharmacogenomic-Guided Warfarin clinical decision support system. [Abstract]. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2011 Oct 26; 10(2):1888.
  4. Russ AL, Militello LG, Saleem JJ, Wears RL, Fairbanks RJ, Karsh B. Human Factors Education for Healthcare Audiences: Ideas for the Way Forward. Human Factors and Ergonomics Society Annual Meeting Proceedings. 2011 Sep 23; CD_ROM(1):808-812.
  5. Saleem JJ, Flanagan M, Militello LG, Arbuckle A, Russ AL, Burgo-Black AL, Doebbeling BN. Paper persistence and computer-based workarounds with the electronic health record in primary care. [Abstract]. Human Factors and Ergonomics Society Annual Meeting Proceedings. 2011 Sep 23; CD-ROM(1):660-664.
  6. Frankel RM, Russ AL, Saleem JJ, Zillich AJ. The Workflow of Computerized Medication Ordering in Primary Care is Not Prescriptive. [Abstract]. Human Factors and Ergonomics Society Annual Meeting Proceedings. 2010 Sep 27; 54(1):840-4.
  7. Russ AL, Saleem JJ, Zillich AJ. Qualitative Study of Medication Alerts and Computerized Prescriber Order Entry (CPOE): Opportunities for Pharmacist Consultation at the Point of Prescribing. [Abstract]. Journal of the American Pharmacists Association : JAPhA. 2010 Jan 1; 50(2):284-285.
  8. Doebbeling BN, Russ AL, Saleem JJ, Zillich AJ. Computerized Medication Alerts and Prescriber Mental Models: Observing Routine Patient Care. [Abstract]. Human Factors and Ergonomics Society Annual Meeting Proceedings. 2009 Oct 1.
Center Products

  1. Russell S, Haggstrom DA, Chumbler NR, Russ AL, Saleem JJ. A novel tool to track and analyze qualitative usability data: Lessons learned from the VA's personal health record in Proceedings of the Human Factors and Ergonomics Society 54th Annual Meeting. 2010 Sep 27; 1264-8.
  2. Doebbeling BN, Saleem JJ, Russ AL. Healthcare Workers' Perceptions of Information in the Electronic Health Record in the Proceedings of the Human Factors and Ergonomics Society, 53rd Annual Meeting. 2009 Oct 19; 635-9.
VA Cyberseminars

  1. Saleem JJ, Frankel RM. Information Resource Center (VIReC), National Cyberseminar series in Clinical Informatics: Effect of Computers at Point of Care. [Cyberseminar]. 2009 Dec 15.
Conference Presentations

  1. Chen S, Zillich AJ, Melton BL, Saleem JJ, Johnson E, Weiner M, Russell SA, McManus MS, Doebbeling BN, Russ AL. The Effect of Redesigned Computerized Drug-Drug Interaction Alerts on Medication Errors and Prescribing Efficiency. Poster session presented at: International Society for Pharmacoeconomics and Outcomes Research Annual Meeting; 2013 May 18; New Orleans, LA.
  2. Chen S, Zillich AJ, Melton BL, Saleem JJ, Johnson E, Weiner M, Russell SA, McManus MS, Doebbeling BN, Russ AL. Redesigned Drug-Drug Interaction Alerts Reduced Medication Errors and Improved Prescribing Efficiency. Paper presented at: Great Lakes Pharmacy Resident Annual Conference; 2013 Apr 24; West Lafayette, IN.
  3. Russ AL, Zillich AJ, Melton B, Spina J, Weiner M, Russell SA, McManus MS, Kobylinski A, Doebbeling BN, Hawsey J, Puleo A, Johnson E, Saleem JJ. Applying Human Factors Principles to Improve Medication Alerts. Paper presented at: American Medical Informatics Association Annual Symposium; 2012 Nov 3; Chicago, IL.
  4. Russ AL, Zillich AJ, McManus MS, Doebbeling BN, Saleem JJ. 9 Factors that Influence Prescribers' Response to VA Medication Safety Checks at the Point-of-Care. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 14; National Harbor, MD.
  5. Rajput Z, Mbugua S, Amadi D, Chepng’eno V, Saleem JJ, Anokwa Y, Hartung C, Borriello G, Mamlin B, Ndege S, Were M. Evaluation of an Android-based mHealth system for population surveillance in developing countries. Presented at: American Medical Informatics Association Annual Symposium; 2011 Oct 25; Washington, DC.
  6. Purcell J, Russ AL, Scott J, Drews F, Williams L, Speir R, Saleem JJ. Human Factors Engineering in the Department of Veterans Affairs: Operations and Research Initiatives Related to Health Care Information Technology and Medical Devices. Paper presented at: Human Factors and Ergonomics Society Annual Meeting; 2011 Sep 23; Las Vegas, NV.
  7. Russ AL, Militello LG, Saleem JJ, Wears RL, Fairbanks RJ, Karsh B. Human Factors Education for Healthcare Audiences: Ideas for the Way Forward. Paper presented at: Human Factors and Ergonomics Society Annual Meeting; 2011 Sep 23; Las Vegas, NV.
  8. Saleem JJ, Russ AL. Human factors overview and usability testing. Paper presented at: VA Clinical Application Coordinators Clinical Reminders Fall Assembly; 2010 Oct 20; Indianapolis, IN.
  9. Chumbler NR, Haggstrom DA, Russell S, Saleem JJ, Russ AL. A novel tool to track and analyze qualitative usability data: Lessons learned from the VA's personal health record. Paper presented at: Human Factors and Ergonomics Society Annual Meeting; 2010 Sep 27; San Francisco, CA.
  10. Frankel RM, Russ AL, Saleem JJ, Zillich AJ. The Workflow of Computerized Medication Ordering in Primary Care is Not Prescriptive. Paper presented at: Human Factors and Ergonomics Society Annual Meeting; 2010 Sep 27; San Francisco, CA.
  11. Russ AL, Saleem JJ, Zillich AJ. Medication Order Checks: Design Implications for Prescriber Workflow. Poster session presented at: VA Pharmacy Benefits Management Annual Conference; 2010 May 18; Salt Lake City, UT.
  12. Doebbeling BN, Russ AL, Saleem JJ, Zillich AJ. A Human Factors Investigation of Medication Alerts: Barriers to Prescriber Decision-Making and Clinical Workflow. Paper presented at: American Medical Informatics Association Annual Symposium; 2009 Nov 18; San Francisco, CA.
  13. Doebbeling BN, Russ AL, Saleem JJ. Healthcare Workers' Perceptions of Information in the Electronic Health Record. Paper presented at: Human Factors and Ergonomics Society Annual Meeting; 2009 Oct 19; San Antonio, TX.
  14. Doebbeling BN, Russ AL, Saleem JJ, Zillich AJ. Computerized Medication Alerts and Prescriber Mental Models: Observing Routine Patient Care. Paper presented at: Human Factors and Ergonomics Society Annual Meeting; 2009 Oct 19; San Antonio, TX.


DRA: Health Systems
DRE: Epidemiology, Treatment - Observational, Technology Development and Assessment
Keywords: none
MeSH Terms: none

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