BackgroundElectronic health records (EHR) are becoming increasingly integrated into the clinical environment. With the rapid proliferation of EHRs, a number of studies document an increase in adverse patient safety issues due to the EHR-user interface. Because of these issues, greater attention has been placed on novel educational activities which incorporate use of the EHR. The ICU environment presents many challenges to integrating an EHR given the vast amounts of data recorded each day, which must be interpreted to deliver safe and effective care. We have used a novel EHR based simulation exercise to demonstrate that everyday users fail to recognize a majority of patient safety issues in the ICU. We now sought to determine whether participation in the simulation improves recognition of said issues.MethodsTwo ICU cases were created in our EHR simulation environment. Each case contained 14 safety issues, which differed in content but shared common themes. Residents were given 10 minutes to review a case followed by a presentation of management changes. Participants were given an immediate debriefing regarding missed issues and strategies for data gathering in the EHR. Repeated testing was performed in a cohort of subjects with the other case at least 1 week later.Results116 subjects have been enrolled with 25 subjects undergoing repeat testing. There was no difference between cases in recognition of patient safety issues (39.5% vs. 39.4%). Baseline performance for subjects who participated in repeat testing was no different than the cohort as a whole. For both cases, recognition of safety issues was significantly higher among repeat participants compared to first time participants. Further, individual performance improved from 39.9% to 63.6% (p = 0.0002), a result independent of the order in which the cases were employed. The degree of improvement was inversely related to baseline performance. Further, repeat participants demonstrated a higher rate of recognition of changes in vitals, misdosing of antibiotics and oversedation compared to first time participants.ConclusionParticipation in EHR simulation improves EHR use and identification of patient safety issues.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6920-14-224) contains supplementary material, which is available to authorized users.

Numerous reports describe unintended consequences of electronic health record implementation. Having previously described physicians' failures to recognize patient safety issues within our electronic health record simulation environment, we now report on our use of eye and screen-tracking technology to understand factors associated with poor error recognition during an intensive care unit-based electronic health record simulation. We linked performance on the simulation to standard eye and screen-tracking readouts including number of fixations, saccades, mouse clicks and screens visited. In addition, we developed an overall Composite Eye Tracking score which measured when, where and how often each safety item was viewed. For 39 participants, the Composite Eye Tracking score correlated with performance on the simulation (p = 0.004). Overall, the improved performance was associated with a pattern of rapid scanning of data manifested by increased number of screens visited (p = 0.001), mouse clicks (p = 0.03) and saccades (p = 0.004). Eye tracking can be successfully integrated into electronic health record-based simulation and provides a surrogate measure of cognitive decision making and electronic health record usability.

IntroductionIt is not clear how to effectively recruit healthy research volunteers.MethodsWe developed an electronic health record (EHR)-based algorithm to identify healthy subjects, who were randomly assigned to receive an invitation to join a research registry via the EHR’s patient portal, letters, or phone calls. A follow-up survey assessed contact preferences.ResultsThe EHR algorithm accurately identified 858 healthy subjects. Recruitment rates were low, but occurred more quickly via the EHR patient portal than letters or phone calls (2.7 vs. 19.3 or 10.4 d). Effort and costs per enrolled subject were lower for the EHR patient portal (3.0 vs. 17.3 or 13.6 h, $113 vs. $559 or $435). Most healthy subjects indicated a preference for contact via electronic methods.ConclusionsHealthy subjects can be accurately identified from EHR data, and it is faster and more cost-effective to recruit healthy research volunteers using an EHR patient portal.

With the rapid adoption of electronic health records (EHR), there is a growing appreciation for the central role they play in clinical decision making and team communication, with many studies documenting new safety issues with integration of the EHR into the clinical enterprise. To study these issues, we created a high-fidelity simulation instance of our clinical EHR. In this paper, we describe the impact of integrating the EHR into high-fidelity, interprofessional intensive care unit (ICU) simulations, and the errors induced. We found a number of safety issues directly related to the EHR including alert fatigue, negative impacts on interprofessional communication, and problems with selective data gathering, and these issues were present for all members of the interprofessional team. Through successful integration of the EHR into high-fidelity team-based simulations, we now have an infrastructure to focus educational initiative and deploy informatics solutions to mitigate these safety issues.