A Task Analysis of Emergency Physician Activities in Academic and Community Settings

Chisholm, Carey D.; Weaver, Christopher S.; Whenmouth, Laura F.; Giles, Beverly K.

doi:10.1016/j.annemergmed.2010.11.026

Cited by 87 publications

(87 citation statements)

References 12 publications

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“…In some retrospective reports, the rate of diagnostic errors linked to knowledge deficits is quite low compared to the rate of errors linked to reasoning deficits. 9,10 However, interventions directed at reducing errors by making clinicians aware of cognitive biases have been negative. 14,15 It may well be that there is no Bquick fix^to reduce errors, and strategies should be directed at improving formal and experiential knowledge.…”

Section: Resultsmentioning

confidence: 99%

“…6 Proponents of this dual process model of reasoning argue that improved metacognitive skills (i.e., cognitive forcing strategies 7 ) and a slower, cautious approach can increase reliance on System 2, resulting in more errors being detected and corrected. 2,3,[8][9][10] However, the available scientific evidence does not support this strategy. [14][15][16][17][18][19] Critically, a series of experiments demonstrated that instructing residents to proceed slowly and cautiously when diagnosing written medical cases did not improve diagnostic accuracy compared to being instructed to be more rapid.…”

Section: Introductionmentioning

confidence: 99%

“…20 Still others have suggested that physicians should consider their initial diagnosis to be incorrect and take a critical 'second look'. [8][9][10] In one study of this reflective strategy, participants were asked to list only their initial diagnosis for half the cases. 21 For the other half of cases, they were required to evaluate their initial diagnosis using a series of timeconsuming steps that critically appraised the evidence in the case and identified alternate diagnoses.…”

Section: Introductionmentioning

confidence: 99%

“…Importantly, System 1 is contrasted with System 2, which functions to both detect and correct the biases that lead to error. [1][2][3][4][5] The applied interpretations of this model have had a significant impact on strategies for error reduction [6][7][8][9][10][11][12][13] ; specifically that additional cognitive processing can prevent diagnostic errors. 6 Proponents of this dual process model of reasoning argue that improved metacognitive skills (i.e., cognitive forcing strategies 7 ) and a slower, cautious approach can increase reliance on System 2, resulting in more errors being detected and corrected.…”

Section: Introductionmentioning

confidence: 99%

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Reflecting on Diagnostic Errors: Taking a Second Look is Not Enough

et al. 2015

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BACKGROUND: An experimenter controlled form of reflection has been shown to improve the detection and correction of diagnostic errors in some situations; however, the benefits of participant-controlled reflection have not been assessed. OBJECTIVE: The goal of the current study is to examine how experience and a self-directed decision to reflect affect the accuracy of revised diagnoses. DESIGN: Medical residents diagnosed 16 medical cases (pass 1). Participants were then given the opportunity to reflect on each case and revise their diagnoses (pass 2). PARTICIPANTS: Forty-seven medical Residents in postgraduate year (PGY) 1, 2 and 3 were recruited from Hamilton Health Care Centres. MAIN MEASURES: Diagnoses were scored as 0 (incorrect), 1 (partially correct) and 2 (correct). Accuracies and response times in pass 1 were analyzed using an ANOVA with three factors-PGY, Decision to revise yes/no, and Case 1-16, averaged across residents. The extent to which additional reflection affected accuracy was examined by analyzing only those cases that were revised, using a repeated measures ANOVA, with pass 1 or 2 as a within subject factor, and PGY and Case or Resident as a between-subject factor. KEY RESULTS: The mean score at pass 1 for each level was PGY1, 1.17 (SE 0.50); PGY2, 1.35 (SE 0.67) and PGY3, 1.27 (SE 0.94). While there was a trend for increased accuracy with level, this did not achieve significance. The number of residents at each level who revised at least one diagnosis was 12/19 PGY1 (63 %), 9/11 PGY2 (82 %) and 8/17 PGY3 (47 %). Only 8 % of diagnoses were revised resulting in a small but significant increase in scores from Pass 1 to 2, from 1.20/2 to 1.22 /2 (t=2.15, p=0.03). CONCLUSIONS: Participants did engage in self-directed reflection for incorrect diagnoses; however, this strategy provided minimal benefits compared to knowing the correct answer. Education strategies should be directed at improving formal and experiential knowledge.

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Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Reflecting on Diagnostic Errors: Taking a Second Look is Not Enough

et al. 2015

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“…Emergency physicians often multi-task and frequently transition between activities quickly and unexpectedly while simultaneously handling multiple patients and frequent interruptions [11,12]. In addition, ED patient acuities and patient volumes vary, influencing the ways in which physicians perform routine tasks [13]. Time and motion studies have found that documentation and indirect patient care activities take a significant percentage of provider time [14,15].…”

mentioning

confidence: 99%

Emergency Medicine Resident Physicians’ Perceptions of Electronic Documentation and Workflow

Neri¹,

Redden²,

Poole³

et al. 2015

Appl Clin Inform

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SummaryObjective: To understand emergency department (ED) physicians' use of electronic documentation in order to identify usability and workflow considerations for the design of future ED information system (EDIS) physician documentation modules. Methods: We invited emergency medicine resident physicians to participate in a mixed methods study using task analysis and qualitative interviews. Participants completed a simulated, standardized patient encounter in a medical simulation center while documenting in the test environment of a currently used EDIS. We recorded the time on task, type and sequence of tasks performed by the participants (including tasks performed in parallel). We then conducted semi-structured interviews with each participant. We analyzed these qualitative data using the constant comparative method to generate themes. Results: Eight resident physicians participated. The simulation session averaged 17 minutes and participants spent 11 minutes on average on tasks that included electronic documentation. Participants performed tasks in parallel, such as history taking and electronic documentation. Five of the 8 participants performed a similar workflow sequence during the first part of the session while the remaining three used different workflows. Three themes characterize electronic documentation: (1) physicians report that location and timing of documentation varies based on patient acuity and workload, (2) physicians report a need for features that support improved efficiency; and (3) physicians like viewing available patient data but struggle with integration of the EDIS with other information sources. Conclusion: We confirmed that physicians spend much of their time on documentation (65%) during an ED patient visit. Further, we found that resident physicians did not all use the same workflow and approach even when presented with an identical standardized patient scenario. Future EHR design should consider these varied workflows while trying to optimize efficiency, such as improving integration of clinical data. These findings should be tested quantitatively in a larger, representative study. Research Article P.M. Neri et al.: Physicians' Perceptions of Electronic Documentation and WorkflowFor personal or educational use only. No other uses without permission. All rights reserved. BackgroundElectronic clinical documentation serves multiple purposes including communication, billing, maintenance of a legal record, and serves as a tool for synthesis and medical decision making. Electronic Health Record (EHR) incentive programs in the United States designed to stimulate health information technology (HIT) adoption require hospitals and providers to show they use the EHR "meaningfully" and meet certain objectives in order to receive incentive payments. The second stage of the meaningful use program recognizes the importance of electronic documentation by including it as a menu objective to fulfill program requirements [1]. In response to these policies and incentives, emergency departments (EDs)...

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Developing and Evaluating Large Language Model–Generated Emergency Medicine Handoff Notes

Hartman,

Zhang,

Poddar

et al. 2024

JAMA Netw Open

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ImportanceAn emergency medicine (EM) handoff note generated by a large language model (LLM) has the potential to reduce physician documentation burden without compromising the safety of EM-to-inpatient (IP) handoffs.ObjectiveTo develop LLM-generated EM-to-IP handoff notes and evaluate their accuracy and safety compared with physician-written notes.Design, Setting, and ParticipantsThis cohort study used EM patient medical records with acute hospital admissions that occurred in 2023 at NewYork-Presbyterian/Weill Cornell Medical Center. A customized clinical LLM pipeline was trained, tested, and evaluated to generate templated EM-to-IP handoff notes. Using both conventional automated methods (ie, recall-oriented understudy for gisting evaluation [ROUGE], bidirectional encoder representations from transformers score [BERTScore], and source chunking approach for large-scale inconsistency evaluation [SCALE]) and a novel patient safety-focused framework, LLM-generated handoff notes vs physician-written notes were compared. Data were analyzed from October 2023 to March 2024.ExposureLLM-generated EM handoff notes.Main Outcomes and MeasuresLLM-generated handoff notes were evaluated for (1) lexical similarity with respect to physician-written notes using ROUGE and BERTScore; (2) fidelity with respect to source notes using SCALE; and (3) readability, completeness, curation, correctness, usefulness, and implications for patient safety using a novel framework.ResultsIn this study of 1600 EM patient records (832 [52%] female and mean [SD] age of 59.9 [18.9] years), LLM-generated handoff notes, compared with physician-written ones, had higher ROUGE (0.322 vs 0.088), BERTScore (0.859 vs 0.796), and SCALE scores (0.691 vs 0.456), indicating the LLM-generated summaries exhibited greater similarity and more detail. As reviewed by 3 board-certified EM physicians, a subsample of 50 LLM-generated summaries had a mean (SD) usefulness score of 4.04 (0.86) out of 5 (compared with 4.36 [0.71] for physician-written) and mean (SD) patient safety scores of 4.06 (0.86) out of 5 (compared with 4.50 [0.56] for physician-written). None of the LLM-generated summaries were classified as a critical patient safety risk.Conclusions and RelevanceIn this cohort study of 1600 EM patient medical records, LLM-generated EM-to-IP handoff notes were determined superior compared with physician-written summaries via conventional automated evaluation methods, but marginally inferior in usefulness and safety via a novel evaluation framework. This study suggests the importance of a physician-in-loop implementation design for this model and demonstrates an effective strategy to measure preimplementation patient safety of LLM models.

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A Task Analysis of Emergency Physician Activities in Academic and Community Settings

Cited by 87 publications

References 12 publications

Reflecting on Diagnostic Errors: Taking a Second Look is Not Enough

Reflecting on Diagnostic Errors: Taking a Second Look is Not Enough

Emergency Medicine Resident Physicians’ Perceptions of Electronic Documentation and Workflow

Developing and Evaluating Large Language Model–Generated Emergency Medicine Handoff Notes

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