First name
Dean
Last name
Karavite

Title

Human-centered development of an electronic health record-embedded, interactive information visualization in the emergency department using fast healthcare interoperability resources.

Year of Publication

2021

Date Published

2021 Mar 03

ISSN Number

1527-974X

Abstract

<p><strong>OBJECTIVE: </strong>Develop and evaluate an interactive information visualization embedded within the electronic health record (EHR) by following human-centered design (HCD) processes and leveraging modern health information exchange standards.</p>

<p><strong>MATERIALS AND METHODS: </strong>We applied an HCD process to develop a Fast Healthcare Interoperability Resources (FHIR) application that displays a patient's asthma history to clinicians in a pediatric emergency department. We performed a preimplementation comparative system evaluation to measure time on task, number of screens, information retrieval accuracy, cognitive load, user satisfaction, and perceived utility and usefulness. Application usage and system functionality were assessed using application logs and a postimplementation survey of end users.</p>

<p><strong>RESULTS: </strong>Usability testing of the Asthma Timeline Application demonstrated a statistically significant reduction in time on task (P &lt; .001), number of screens (P &lt; .001), and cognitive load (P &lt; .001) for clinicians when compared to base EHR functionality. Postimplementation evaluation demonstrated reliable functionality and high user satisfaction.</p>

<p><strong>DISCUSSION: </strong>Following HCD processes to develop an application in the context of clinical operations/quality improvement is feasible. Our work also highlights the potential benefits and challenges associated with using internationally recognized data exchange standards as currently implemented.</p>

<p><strong>CONCLUSION: </strong>Compared to standard EHR functionality, our visualization increased clinician efficiency when reviewing the charts of pediatric asthma patients. Application development efforts in an operational context should leverage existing health information exchange standards, such as FHIR, and evidence-based mixed methods approaches.</p>

DOI

10.1093/jamia/ocab016

Alternate Title

J Am Med Inform Assoc

PMID

33682004

Title

Formative Usability Testing Reduces Severe Blood Product Ordering Errors.

Year of Publication

2019

Number of Pages

981-990

Date Published

2019 Oct

ISSN Number

1869-0327

Abstract

<p><strong>BACKGROUND: </strong> Medical errors in blood product orders and administration are common, especially for pediatric patients. A failure modes and effects analysis in our health care system indicated high risk from the electronic blood ordering process.</p>

<p><strong>OBJECTIVES: </strong> There are two objectives of this study as follows:(1) To describe differences in the design of the original blood product orders and order sets in the system (original design), new orders and order sets designed by expert committee (DEC), and a third-version developed through user-centered design (UCD).(2) To compare the number and type of ordering errors, task completion rates, time on task, and user preferences between the original design and that developed via UCD.</p>

<p><strong>METHODS: </strong> A multidisciplinary expert committee proposed adjustments to existing blood product order sets resulting in the DEC order set. When that order set was tested with front-line users, persistent failure modes were detected, so orders and order sets were redesigned again via formative usability testing. Front-line users in their native clinical workspaces were observed ordering blood in realistic simulated scenarios using a think-aloud protocol. Iterative adjustments were made between participants. In summative testing, participants were randomized to use the original design or UCD for five simulated scenarios. We evaluated differences in ordering errors, time on task, and users' design preference with two-sample -tests.</p>

<p><strong>RESULTS: </strong> Formative usability testing with 27 providers from seven specialties led to 18 changes made to the DEC to produce the UCD. In summative testing, error-free task completion for the original design was 36%, which increased to 66% in UCD (30%, 95% confidence interval [CI]: 3.9-57%;  = 0.03). Time on task did not vary significantly.</p>

<p><strong>CONCLUSION: </strong> UCD led to substantially different blood product orders and order sets than DEC. Users made fewer errors when ordering blood products for pediatric patients in simulated scenarios when using the UCD orders and order sets compared with the original design.</p>

DOI

10.1055/s-0039-3402714

Alternate Title

Appl Clin Inform

PMID

31875648

Title

A Heuristic Evaluation to Assess Use of After Visit Summaries for Supporting Continuity of Care.

Year of Publication

2018

Number of Pages

714-724

Date Published

2018 07

ISSN Number

1869-0327

Abstract

<p><strong>BACKGROUND: </strong>Outpatient providers often do not receive discharge summaries from acute care providers prior to follow-up visits. These outpatient providers may use the after-visit summaries (AVS) that are given to patients to obtain clinical information. It is unclear how effectively AVS support care coordination between clinicians.</p>

<p><strong>OBJECTIVES: </strong>Goals for this effort include: (1) developing usability heuristics that may be applied both for assessment and to guide generation of medical documents in general, (2) conducting a heuristic evaluation to assess the use of AVS for communication between clinicians, and (3) providing recommendations for generating AVS that effectively support both patient/caregiver use and care coordination.</p>

<p><strong>METHODS: </strong>We created a 17-item heuristic evaluation instrument for assessing usability of medical documents. Eight experts used the instrument to assess each of four simulated AVS. The simulations were created using examples from two hospitals and two pediatric patient cases developed by the National Institute of Standards and Technology.</p>

<p><strong>RESULTS: </strong>Experts identified 224 unique usability problems ranging in severity from mild to catastrophic. Content issues (e.g., missing medical history, marital status of a 2-year-old) were rated as most severe, but widespread formatting and structural problems (e.g., inconsistent indentation, fonts, and headings; confusing ordering of information) were so distracting that they significantly reduced readers' ability to efficiently use the documents. Overall, issues in the AVS from Hospital 2 were more severe than those in the AVS from Hospital 1.</p>

<p><strong>CONCLUSION: </strong>The new instrument allowed for quick, inexpensive evaluations of AVS. Usability issues such as unnecessary information, poor organization, missing information, and inconsistent formatting make it hard for patients, caregivers, and clinicians to use the AVS. The heuristics in the new instrument may be used as guidance to adapt electronic health record systems so that they generate more useful and usable medical documents.</p>

DOI

10.1055/s-0038-1668093

Alternate Title

Appl Clin Inform

PMID

30208496

Title

Development and dissemination of clinical decision support across institutions: standardization and sharing of refugee health screening modules.

Year of Publication

2019

Date Published

2019 Aug 02

ISSN Number

1527-974X

Abstract

<p><strong>OBJECTIVES: </strong>We developed and piloted a process for sharing guideline-based clinical decision support (CDS) across institutions, using health screening of newly arrived refugees as a case example.</p>

<p><strong>MATERIALS AND METHODS: </strong>We developed CDS to support care of newly arrived refugees through a systematic process including a needs assessment, a 2-phase cognitive task analysis, structured preimplementation testing, local implementation, and staged dissemination. We sought consensus from prospective users on CDS scope, applicable content, basic supported workflows, and final structure. We documented processes and developed sharable artifacts from each phase of development. We publically shared CDS artifacts through online dissemination platforms. We collected feedback and implementation data from implementation sites.</p>

<p><strong>RESULTS: </strong>Responses from 19 organizations demonstrated a need for improved CDS for newly arrived refugee patients. A guided multicenter workflow analysis identified 2 main workflows used by organizations that would need to be supported by shared CDS. We developed CDS through an iterative design process, which was successfully disseminated to other sites using online dissemination repositories. Implementation sites had a small-to-modest analyst time commitment but reported a good match between CDS and workflow.</p>

<p><strong>CONCLUSION: </strong>Sharing of CDS requires overcoming technical and workflow barriers. We used a guided multicenter workflow analysis and online dissemination repositories to create flexible CDS that has been adapted at 3 sites. Organizations looking to develop sharable CDS should consider evaluating the workflows of multiple institutions and collecting feedback on scope, design, and content in order to make a more generalizable product.</p>

DOI

10.1093/jamia/ocz124

Alternate Title

J Am Med Inform Assoc

PMID

31373356

Title

Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings.

Year of Publication

2018

Number of Pages

1752-1759

Date Published

2018 11

ISSN Number

1544-5208

Abstract

<p>Pediatric populations are uniquely vulnerable to the usability and safety challenges of electronic health records (EHRs), particularly those related to medication, yet little is known about the specific issues contributing to hazards. To understand specific usability issues and medication errors in the care of children, we analyzed 9,000 patient safety reports, made in the period 2012-17, from three different health care institutions that were likely related to EHR use. Of the 9,000 reports, 3,243 (36&nbsp;percent) had a usability issue that contributed to the medication event, and 609 (18.8&nbsp;percent) of the 3,243 might have resulted in patient harm. The general pattern of usability challenges and medication errors were the same across the three sites. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing.</p>

DOI

10.1377/hlthaff.2018.0699

Alternate Title

Health Aff (Millwood)

PMID

30395517

Title

Adoption of a Portal for the Primary Care Management of Pediatric Asthma: A Mixed-Methods Implementation Study.

Year of Publication

2016

Number of Pages

e172

Date Published

2016

ISSN Number

1438-8871

Abstract

<p><strong>BACKGROUND: </strong>Patient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established.</p>

<p><strong>OBJECTIVE: </strong>We evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success.</p>

<p><strong>METHODS: </strong>We conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework.</p>

<p><strong>RESULTS: </strong>We invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P&lt;.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success.</p>

<p><strong>CONCLUSIONS: </strong>Although use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children.</p>

<p><strong>CLINICALTRIAL: </strong>Clinicaltrials.gov NCT01966068; https://clinicaltrials.gov/ct2/show/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3).</p>

DOI

10.2196/jmir.5610

Alternate Title

J. Med. Internet Res.

PMID

27357835

Title

A survey of informatics approaches to whole-exome and whole-genome clinical reporting in the electronic health record.

Year of Publication

2013

Number of Pages

824-32

Date Published

2013 Oct

ISSN Number

1530-0366

Abstract

<p><strong>PURPOSE: </strong>Genome-scale clinical sequencing is being adopted more broadly in medical practice. The National Institutes of Health developed the Clinical Sequencing Exploratory Research (CSER) program to guide implementation and dissemination of best practices for the integration of sequencing into clinical care. This study describes and compares the state of the art of incorporating whole-exome and whole-genome sequencing results into the electronic health record, including approaches to decision support across the six current CSER sites.</p>

<p><strong>METHODS: </strong>The CSER Medical Record Working Group collaboratively developed and completed an in-depth survey to assess the communication of genome-scale data into the electronic health record. We summarized commonalities and divergent approaches.</p>

<p><strong>RESULTS: </strong>Despite common sequencing platform (Illumina) adoptions, there is a great diversity of approaches to annotation tools and workflow, as well as to report generation. At all sites, reports are human-readable structured documents available as passive decision support in the electronic health record. Active decision support is in early implementation at two sites.</p>

<p><strong>CONCLUSION: </strong>The parallel efforts across CSER sites in the creation of systems for report generation and integration of reports into the electronic health record, as well as the lack of standardized approaches to interfacing with variant databases to create active clinical decision support, create opportunities for cross-site and vendor collaborations.</p>

DOI

10.1038/gim.2013.120

Alternate Title

Genet. Med.

PMID

24071794

Title

Effectiveness of decision support for families, clinicians, or both on HPV vaccine receipt.

Year of Publication

2013

Number of Pages

1114-24

Date Published

2013 Jun

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVE: </strong>To improve human papillomavirus (HPV) vaccination rates, we studied the effectiveness of targeting automated decision support to families, clinicians, or both.</p>

<p><strong>METHODS: </strong>Twenty-two primary care practices were cluster-randomized to receive a 3-part clinician-focused intervention (education, electronic health record-based alerts, and audit and feedback) or none. Overall, 22, 486 girls aged 11 to 17 years due for HPV vaccine dose 1, 2, or 3 were randomly assigned within each practice to receive family-focused decision support with educational telephone calls. Randomization established 4 groups: family-focused, clinician-focused, combined, and no intervention. We measured decision support effectiveness by final vaccination rates and time to vaccine receipt, standardized for covariates and limited to those having received the previous dose for HPV #2 and 3. The 1-year study began in May 2010.</p>

<p><strong>RESULTS: </strong>Final vaccination rates for HPV #1, 2, and 3 were 16%, 65%, and 63% among controls. The combined intervention increased vaccination rates by 9, 8, and 13 percentage points, respectively. The control group achieved 15% vaccination for HPV #1 and 50% vaccination for HPV #2 and 3 after 318, 178, and 215 days. The combined intervention significantly accelerated vaccination by 151, 68, and 93 days. The clinician-focused intervention was more effective than the family-focused intervention for HPV #1, but less effective for HPV #2 and 3.</p>

<p><strong>CONCLUSIONS: </strong>A clinician-focused intervention was most effective for initiating the HPV vaccination series, whereas a family-focused intervention promoted completion. Decision support directed at both clinicians and families most effectively promotes HPV vaccine series receipt.</p>

DOI

10.1542/peds.2012-3122

Alternate Title

Pediatrics

PMID

23650297

Title

The implementation and acceptability of an HPV vaccination decision support system directed at both clinicians and families.

Year of Publication

2012

Number of Pages

616-24

Date Published

2012

ISSN Number

1942-597X

Abstract

<p>We developed an electronic medical record (EMR)-based HPV vaccine decision support intervention targeting clinicians, (immunization alerts, education, and feedback) and families (phone reminders and referral to an educational website). Through telephone surveys completed by 162 parents of adolescent girls, we assessed the acceptability of the family-focused intervention and its effect on information-seeking behavior, communication, and HPV vaccine decision-making. The intervention was acceptable to parents and 46% remembered receiving the reminder call. Parents reported that the call prompted them to seek out information regarding the HPV vaccine, discuss the vaccine with friends and family, and reach a decision. Parents whose adolescent girls attended practices receiving the clinician-focused intervention were more likely to report that their clinician discussed the HPV vaccine at preventive visits. The results of this study demonstrate the acceptability and potential impact on clinical care of a comprehensive decision support system directed at both clinicians and families.</p>

Alternate Title

AMIA Annu Symp Proc

PMID

23304334

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