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Health Services Research & Development

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CDA 09-024 – HSR&D Study

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

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.

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.

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.

Not yet available.

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.

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None at this time.

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

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