Should US doctors embrace electronic health records?

Gellert, George A.; Webster, S. Luke; Gillean, John A.; Melnick, Edward R.; Kanzaria, Hemal K.

doi:10.1136/bmj.j242

Cited by 11 publications

(9 citation statements)

References 7 publications

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“…Design, development, and formative evaluation were informed by the philosophy that technology can accelerate the provision of evidence-based care that is efficient and empathic, effectively reducing unnecessary care [17,19,24]. The user can traverse the app in its entirety in 3 to 5 screen taps.…”

Section: Discussionmentioning

confidence: 99%

“…Unfortunately, contemporary electronic health records (EHRs) tend to impede conversation [20-24]. The EHR interface physically separates the clinician from the patient, compromising communication.…”

Section: Introductionmentioning

confidence: 99%

“…A large-scale study of EHR implementation found no negative association with mortality or adverse events across 17 hospitals [31]. EHR implementation has done harm in other ways [21,24,30]. Ratanawongsa et al [21] found high computer use by clinicians to be associated with lower patient satisfaction and communication.…”

Section: Introductionmentioning

confidence: 99%

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Patient-Centered Decision Support: Formative Usability Evaluation of Integrated Clinical Decision Support With a Patient Decision Aid for Minor Head Injury in the Emergency Department

et al. 2017

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BackgroundThe Canadian Computed Tomography (CT) Head Rule, a clinical decision rule designed to safely reduce imaging in minor head injury, has been rigorously validated and implemented, and yet expected decreases in CT were unsuccessful. Recent work has identified empathic care as a key component in decreasing CT overuse. Health information technology can hinder the clinician-patient relationship. Patient-centered decision tools to support the clinician-patient relationship are needed to promote evidence-based decisions.ObjectiveOur objective is to formatively evaluate an electronic tool that not only helps clinicians at the bedside to determine the need for CT use based on the Canadian CT Head Rule but also promotes evidence-based conversations between patients and clinicians regarding patient-specific risk and patients’ specific concerns.MethodsUser-centered design with practice-based and participatory decision aid development was used to design, develop, and evaluate patient-centered decision support regarding CT use in minor head injury in the emergency department. User experience and user interface (UX/UI) development involved successive iterations with incremental refinement in 4 phases: (1) initial prototype development, (2) usability assessment, (3) field testing, and (4) beta testing. This qualitative approach involved input from patients, emergency care clinicians, health services researchers, designers, and clinical informaticists at every stage.ResultsThe Concussion or Brain Bleed app is the product of 16 successive iterative revisions in accordance with UX/UI industry design standards. This useful and usable final product integrates clinical decision support with a patient decision aid. It promotes shared use by emergency clinicians and patients at the point of care within the emergency department context. This tablet computer app facilitates evidence-based conversations regarding CT in minor head injury. It is adaptable to individual clinician practice styles. The resultant tool includes a patient injury evaluator based on the Canadian CT Head Rule and provides patient specific risks using pictographs with natural frequencies and cues for discussion about patient concerns.ConclusionsThis tool was designed to align evidence-based practices about CT in minor head injury patients. It establishes trust, empowers active participation, and addresses patient concerns and uncertainty about their condition. We hypothesize that, when implemented, the Concussion or Brain Bleed app will support—not hinder—the clinician-patient relationship, safely reduce CT use, and improve the patient experience of care.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Patient-Centered Decision Support: Formative Usability Evaluation of Integrated Clinical Decision Support With a Patient Decision Aid for Minor Head Injury in the Emergency Department

et al. 2017

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“…However, these strategies have had limited success for this decision, likely due to nonclinical factors such as patients’ concerns with their condition and care [ 12 - 15 ]. Findings of this study suggest that patients can be educated and engaged in the ED setting in decisions about CT imaging for low-risk minor head injury using a health information technology interface that supports the clinician-patient relationship (rather than getting in its way) [ 17 , 38 , 39 ]. Specifically, if these findings are confirmed in a larger effectiveness trial, it would imply that successful adoption of the Concussion or Brain Bleed app could help address nonclinical factors that contribute to overuse of CT in minor head injury that are not addressed with traditional implementation strategies and traditional CDS.…”

Section: Discussionmentioning

confidence: 99%

Tablet-Based Patient-Centered Decision Support for Minor Head Injury in the Emergency Department: Pilot Study

Singh¹,

Hess

Guo

et al. 2017

JMIR Mhealth Uhealth

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BackgroundThe Concussion or Brain Bleed app is a clinician- and patient-facing electronic tool to guide decisions about head computed tomography (CT) use in patients presenting to the emergency department (ED) with minor head injury. This app integrates a patient decision aid and clinical decision support (using the Canadian CT Head Rule, CCHR) at the bedside on a tablet computer to promote conversations around individualized risk and patients’ specific concerns within the ED context.ObjectiveThe objective of this study was to describe the use of the Concussion or Brain Bleed app in a high-volume ED and to establish preliminary efficacy estimates on patient experience, clinician experience, health care utilization, and patient safety. These data will guide the planning of a larger multicenter trial testing the effectiveness of the Concussion or Brain Bleed app.MethodsWe conducted a prospective pilot study of adult (age 18-65 years) patients presenting to the ED after minor head injury who were identified by participating clinicians as low risk by the CCHR. The primary outcome was patient knowledge regarding the injury, risks, and CT use. Secondary outcomes included patient satisfaction, decisional conflict, trust in physician, clinician acceptability, system usability, Net Promoter scores, head CT rate, and patient safety at 7 days.ResultsWe enrolled 41 patients cared for by 29 different clinicians. Patient knowledge increased after the use of the app (questions correct out of 9: pre-encounter, 3.3 vs postencounter, 4.7; mean difference 1.4, 95% CI 0.8-2.0). Patients reported a mean of 11.7 (SD 13.5) on the Decisional Conflict Scale and 92.5 (SD 12.0) in the Trust in Physician Scale (both scales range from 0 to 100). Most patients were satisfied with the app’s clarity of information (35, 85%), helpfulness of information (36, 88%), and amount of information (36, 88%). In the 41 encounters, most clinicians thought the information was somewhat or extremely helpful to the patient (35, 85%), would want to use something similar for other decisions (27, 66%), and would recommend the app to other providers (28, 68%). Clinicians reported a mean system usability score of 85.1 (SD 15; scale from 0 to 100 with 85 in the “excellent” acceptability range). The total Net Promoter Score was 36.6 (on a scale from –100 to 100). A total of 7 (17%) patients received a head CT in the ED. No patients had a missed clinically important brain injury at 7 days.ConclusionsAn app to help patients assess the utility of CT imaging after head injury in the ED increased patient knowledge. Nearly all clinicians reported the app to be helpful to patients. The high degree of patient satisfaction, clinician acceptability, and system usability support rigorous testing of the app in a larger multicenter trial.

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“…However, CDS faces its own challenges, including unintended consequences such as alert fatigue and increased cognitive load [18-22]. CDS design principles support careful consideration of the sociotechnical environment and delivery of the right information, to the right person, in the right format, and at the right time in clinical workflow to optimize medical decision making [23-26].…”

Section: Introductionmentioning

confidence: 99%

Computerized Clinical Decision Support System for Emergency Department–Initiated Buprenorphine for Opioid Use Disorder: User-Centered Design

Ray¹,

Ahmed²,

Solad³

et al. 2019

JMIR Hum Factors

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BackgroundEmergency departments (EDs) frequently care for individuals with opioid use disorder (OUD). Buprenorphine (BUP) is an effective treatment option for patients with OUD that can safely be initiated in the ED. At present, BUP is rarely initiated as a part of routine ED care. Clinical decision support (CDS) could accelerate adoption of ED-initiated BUP into routine emergency care.ObjectiveThis study aimed to design and formatively evaluate a user-centered decision support tool for ED initiation of BUP for patients with OUD.MethodsUser-centered design with iterative prototype development was used. Initial observations and interviews identified workflows and information needs. The design team and key stakeholders reviewed prototype designs to ensure accuracy. A total of 5 prototypes were evaluated and iteratively refined based on input from 26 attending and resident physicians.ResultsEarly feedback identified concerns with the initial CDS design: an alert with several screens. The timing of the alert led to quick dismissal without using the tool. User feedback on subsequent iterations informed the development of a flexible tool to support clinicians with varied levels of experience with the intervention by providing both one-click options for direct activation of care pathways and user-activated support for critical decision points. The final design resolved challenging navigation issues through targeted placement, color, and design of the decision support modules and care pathways. In final testing, users expressed that the tool could be easily learned without training and was reasonable for use during routine emergency care.ConclusionsA user-centered design process helped designers to better understand users’ needs for a Web-based clinical decision tool to support ED initiation of BUP for OUD. The process identified varying needs across user experience and familiarity with the protocol, leading to a flexible design supporting both direct care pathways and user-initiated decision support.

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Should US doctors embrace electronic health records?

Cited by 11 publications

References 7 publications

Patient-Centered Decision Support: Formative Usability Evaluation of Integrated Clinical Decision Support With a Patient Decision Aid for Minor Head Injury in the Emergency Department

Patient-Centered Decision Support: Formative Usability Evaluation of Integrated Clinical Decision Support With a Patient Decision Aid for Minor Head Injury in the Emergency Department

Tablet-Based Patient-Centered Decision Support for Minor Head Injury in the Emergency Department: Pilot Study

Computerized Clinical Decision Support System for Emergency Department–Initiated Buprenorphine for Opioid Use Disorder: User-Centered Design

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