Workflow has become a concern regarding electronic health records (EHRs) usefulness and provider satisfaction that has been amplified by the global shortage of physicians and the increase in Veterans seeking healthcare in the VA. Poor usability and system functionality to support clinical tasks are introducing new risks to patient safety, increasing care coordination efforts, and increasing clinical care fragmentation. The lack of support creates inefficiencies demonstrated by task redundancies, barriers, and workarounds. For example, transferring notes between paper and computer are redundant tasks that pose inefficiencies, risk of error, and workflow barriers. Challenges with integrating EHRs into care processes are more evident as providers move across clinics and hospital settings. Despite recent procurement of mobile computers (e.g. iPads, Panasonic Toughbooks), accessing clinical information at the point of care is cumbersome. This study adopts a Veteran-centered, systems-oriented research approach to inform the design of mobile applications (apps).
The objective of this study was to understand physicians' needs and requirements for apps that leverage handheld computing technologies, in pursuit of improved efficiency and healthcare delivery for Veterans at a major, tertiary medical center.
Specific Aim 1: Characterize physicians' needs for mobile apps, by conducting semi-structured interviews, to identify information and functional requirements that will guide the design of workflow-oriented VA apps to enhance Veterans' care.
Specific Aim 2: Assess the real-time use of mobile apps in clinical work environments, by conducting time-motion observations, to understand how apps support clinical tasks in iPad-integrated workflows.
This was a mixed-method study conducted at the Richard L. Roudebush VA Medical Center. Semi-structured interviews were conducted with 24 physicians, averaging 45 minutes. Physicians were stratified among outpatient (12 primary care physicians (PCPs)) and inpatient (12 hospitalists) settings. Interviews were audio-recorded with participants' consent. Transcribed data were coded by four analysts using NVivo 11 software, with both deductive and inductive qualitative approaches. Additionally, 20 time-motion observations were performed with 10 outpatient PCPs and 10 hospitalists in 4-hour blocks. Independent observers noted clinical tasks details.
Despite tasks differences among outpatient PCPs and hospitalists, the lack of mobile access to the EHR presented similar barriers.
Outpatient PCP Task Characterizations: The most frequent tasks are managing alerts (viewing and responding to notifications from other providers or clinics communicated within the EHR), documentation, and medication refills. The most redundant tasks are managing alerts, medication refills, and consultation orders. The most difficult tasks are medical-record review, documentation, and managing alerts.
Hospitalist Task Characterizations: The most frequent tasks are medical-record review, documentation, and orders. The most redundant tasks are documentation, orders, and medical-record review. The most difficult tasks are orders, medical-record review, and admitting and discharging patients.
Outpatient PCP Observations: Indirect care activities occupied 45% (SD=15) of observations, and direct care activities occupied 28% (SD=12). Of observed time, 44% (SD=17) was spent interacting with patients or caregivers. Desktop computer software and paper were used for 64% (SD=12) and 29% (SD=24) of the observed time, respectively. Mobile software was used 1.1% (SD=0.6) of the time.
Hospitalist Observations: Indirect care activities occupied 38% (SD=17) of observations, and direct care activities occupied 22% (SD=11). The remainder was spent on care coordination (M=13%, SD=10) and administrative or other work (M=8 %, SD=6). Nine percent of observed time involved multiple tasks conducted together (multitasking). Most time was spent in staff offices (M=39%, SD=28). Another 18% (SD=18) was spent in hallways, stairs, and elevators. Most time spent sending or receiving information (combined) was with other people (M=52%, SD=17); the least time was with mobile software (M=1%, SD=1).
Integrated Findings: Overall, for both outpatient PCPs and hospitalists, there is a need for mobile apps that enable providers to document and review notes and orders beyond charting and exam rooms. Lack of mobile access to the EHR via user-friendly devices and software apps caused outpatient PCPs and hospitalists to create workarounds and depend on paper, which is prone to inefficient data entry and retrieval, increased risk of human error, and reliance on potentially outdated data at the point of care.
This pilot provides evidence to support the design, development, and implementation of mobile apps that address the most frequent, redundant, and difficult tasks for physicians across outpatient and inpatient settings.
Our research team is establishing meetings with local and national operational partners. Locally, at the Richard L. Roudebush VA Medical Center, we are collaborating with leaders in operations, to aid in the deployment of new mobile devices to outpatient PCPs. Our findings will assist the prioritization of distribution and integration of these devices into workflows with maximum potential benefit. Nationally, the VA Office of Connected Care will meet with our team to discuss our findings and options for related VA mobile app development with the VA Mobile platform and VA App Store. The design of evidence-based mobile applications stemming from this pilot can increase physician efficiency, reduce physician dependency on paper, and increase patient safety.
Future research efforts will include a collaborative proposal, with our operational partners, to investigate the implementation of evidence-based mobile apps and the impact on Veteran-centered care.
None at this time.
Technology Development and Assessment, Treatment - Implementation, TRL - Applied/Translational
Care Management Tools, Decision Support, Technology Development