Matching EHR Tool to Task: Making it Easier to Care

The Patient and the Electronic Health Record: Where are we? Where are we going?

Matching EHR Tool to Task: Making It Easier to CareI-PrACTISE | April 2016

Jeffery L. Belden, MD | ProfessorRichelle J. Koopman, MD, MS | Associate Professor

UNIVERSITY OF MISSOURIFamily & Community Medicine

UNIVERSITY OF MISSOURIFamily & Community Medicine1David

AcknowledgementsWe have no conflicts to declare.

Grant support includes:Grant #1R01HS023328 from AHRQ. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.California HealthCare Foundation and SHARP-C Project of the ONC supported inspiredEHRs.org.


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ObjectivesDemonstrate human factors principles at work in EHR designExamine the influence on the physical environment on the work of primary care office visits Forecast future trends in EHR design


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Designing EHR toolsUnderstanding the information needs of the userUnderstanding the tasks of the userUnderstanding the context of the workDesigning to make information clearerDesigning to aid decision-making


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Our history


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EHR evolutionStand-alone in your office/hospitalAble to get labsAble to get discharge summariesAble to see ER and consultant reports, link hospital and officeE-prescribingPatient portalsHealth Information Exchange (HIE)


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Our history


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Tabbed Dividers


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Working Memory


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Cognitive Load


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Start a note by dumping the data into the note for review

Health Status Allergies: . Allergic Reactions (Selected)Lamisil- Rash.Severity not DocumentedLevaquin- Rash, hives. Current medications: Medication Orders (selected)amloDIPINE 10 mg Tab, 10 mg, 1 Tablet, Oral, qAMhydrochlorothiazide 25 mg Tab, 25 mg, 1 Tablet, Oral, qAMPrescriptions and Home Medications (selected)fluticasone (Flovent), 88 mcg 2 puffs daily, 1hr AC, 2 Each, 0methylphenidate (Metadate CD 20 mg/24 hr oral capsule, extended release), 20 mg, 1 Capsule, Oral, qAM, 30 Capsule, 0 Problem list: All Problems (Selected)Smoker / ICD-9-CM 305.1 / ConfirmedMigraine HAs / ICD-9-CM 346.01 / ConfirmedHypertension / ICD-9-CM 997.91 / ConfirmedCalculus of kidney / ICD-9-CM 592.0 / Confirmed Review of Systems Constitutional: Fever, Fatigue, Decreased activity. Eye: No discharge. Ear/Nose/Mouth/Throat: No ear pain, No nasal congestion. Respiratory: No shortness of breath, No cough. Cardiovascular: No chest pain. Gastrointestinal: No nausea, No vomiting, No diarrhea, No constipation, No abdominal pain. Genitourinary: No dysuria. Endocrine: No excessive thirst, No polyuria. Immunologic: No recurrent fevers, No recurrent infections. Musculoskeletal: Muscle pain, No neck pain. Integumentary: No rash. Neurologic: Headache. Psychiatric: Negative.


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Cognitive OverloadInformation to be processed exceeds the processor, i.e. working memory


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Dashboard Design


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Dashboard Design: Nudge


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Dashboard EfficienciesSaved over 4 minutesSaved 50 clicksIncreased accuracy

Satisfaction and Satisficing


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Seeing the big picture


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My MissionEmpathy for the user

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My MissionTo relieve physician suffering by improving the usability of the software they use

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My MissionTo bring physicians joy by making their software delightful to use

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The VisionInspired EHRs: Designing for CliniciansFor HIT vendorsFree, online at inspiredEHRs.org

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The Medication ListMore like a dozen listsStarted with an idea about

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Varieties of Medication ListsProvider viewsSimple ListTreatment & Renewals List Timeline ViewBurst or intermittent therapyPeri-proceduralTried and FailedMedication Reconciliation ListPatient viewsBasic Pocket ListDaily Reminder ListReminder for Refills ListEnd of Visit ListRestock the Medi-minder List more complexmore complex

Note the users. Note the complexity range.23

Which Medication List

User?Task at hand?


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Reading the Medication List

in a progress note


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UNIVERSITY OF MISSOURIFamily & Community MedicineAnother Medication List

for managing medication renewals


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UNIVERSITY OF MISSOURIFamily & Community MedicineChallengesWhy cant clinicians get what they want?Now!

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Design Thinking


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desirablefeasiblecliniciansengineers

desirablefeasibleviablecliniciansengineersvendors

ChallengesFundingSetting Scope

Building the teamVendors | Human Factors | Designers | Clinicians

Selling the conceptinspirational, not prescriptive


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ChallengesWhats in a name?

Style GuideThou shall

Inspired EHRs:Designing for Clinicians


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UNIVERSITY OF MISSOURIFamily & Community MedicineClinical ScenariosEmpathize with the clinicians thinking

ImagesBefore & After Comparisons

Links to HF Principles

Jump to HF Chapter

with examplesgeneral example

specific to EHRHIT specific example

TwinlistMedication Reconciliation | Prototype

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Twinlist videoPlay bit.ly/TwinlistVideo

TimelineThe story of the medicationsWhen did we start?Why / when did we stop?Why did we change?Why arent you taking what I expected?

So hard to find

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Timeline | starting with sketchs

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Timeline Prototype

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Timeline Prototype

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Toll, E.The Cost of TechnologyJAMA 2012.Technology in the Exam Room

Typical Exam Room

Something new? Better?

MethodsVideo-recorded 60 patient visits for chronic care follow-up in 2 practices5 patients each for 12 docsCoded videos for physician and patient gazePhysician-patientPhysician-computerPatient-computerIncidental viewingCollaborative viewing

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Time Spent (minutes)Laptops30 inch screensp valueTotal Visit18.721.70.06Patient Physician Mutual Gaze15.015.90.52Physician alone viewing screen5.53.20.01Collaborative viewing of screen0.61.60.03

Compared to laptop rooms (32%) patients invited to view the screen in 63% of visits in 30 inch screen rooms, p = 0.03

Backwards?

Better

Compared to laptop rooms (32%) patients invited to view the screen in 63% of visits in 30 inch screen rooms, p = 0.03

Tables and GraphsWhen tables were viewed (45% of visits), they were shared with patients 38% of the timeWhen graphs were viewed (18% of visits), they were shared with patients 100% of the time

It gives you more of a perspective. Numbers dont mean a whole lot. But when you can see the curvature and the form that it takes you have a better perspective of what is going on.

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BP Graphing

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iPad graph

Margaret

Incorporating Home BP

UNIVERSITY OF MISSOURIFamily & Community MedicineAdding a medication timeline

UNIVERSITY OF MISSOURIFamily & Community MedicineOutlier Fills?

UNIVERSITY OF MISSOURIFamily & Community MedicineReal Home BP Data

UNIVERSITY OF MISSOURIFamily & Community MedicineFuture EHR Tool DesignDesign for shared physician-patient experienceIncorporate patient-generated dataMoving from page paradigm to data visualizationPayment regulation reform needed


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Questions?


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Questions?Richelle Koopman MD [email protected]

Jeff Belden [email protected]: jeffbeldeninspiredEHRs.orgtoomanyclicks.com


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Matching EHR Tool to Task: Making it Easier to Care

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