CONTACTS
SUBJECTS
VA Quality Care Electronic Medical Records EMR Case Management Conte
2903 -
2903 - ..
2904 - Summary/Objective
2905 -
290501 - Follow up ref SDS 8 I55I, ref SDS 7 JF9K.
290502 -
290503 -
290504 -
290505 -
290507 - ..
2906 -
2907 -
2908 - Progress
2909 -
290901 - The VA has been recognized in recent years for outstanding medical
290902 - care. Many articles cite VA reliance on computerized medical records
290903 - for driving improvement of quality care, reported recently on 091106
290904 - 1000. ref SDS 9 1Z5N
290906 - ..
290907 - Experience working with the VA since 2005 supports published reports
290908 - that the VA has moved ahead in providing quality care....
290909 -
290910 - 1. VA staff facilitates giving primary care
290911 - doctor opportunity to leave staff meeting
290912 - for 10 minutes to order referral for
290913 - immediate examination of eye infection
290914 - based on patients notice in electronic
290915 - letter (email), which the doctor
290916 - used to enter electronic
290917 - referral........................... 070221 0819, ref SDS 4 0001
290919 - ..
290920 - 2. Doctor Margulies courteous, professional
290921 - consideration notifying patient of backlog
290922 - and expected wait time for exigent
290923 - eye examination.................... 070221 0819, ref SDS 4 PQ7W
290925 - ..
290926 - 3. Doctor Margulies invested 10 minutes to
290927 - review prior record correlating history of
290928 - eye problems to assess new problem reported
290929 - today; and commented on "miracle" of
290930 - timely access for accurate understanding
290931 - of patient medical
290932 - trends............................. 070221 0819, ref SDS 4 5D88
290934 - ..
290935 - 4. Doctor refuses to transmit work record
290936 - electronically to the patient, which she
290937 - found extremely efficient for accurate
290938 - understanding, and because VA management
290939 - is more afraid of being criticized for
290940 - disclosure of confidential patient health
290941 - records, than of causing patient medical
290942 - problems, including death from failure
290943 - to provide accurate record in time
290944 - to be effective.................... 070221 0819, ref SDS 4 QE4N
290946 - ..
290947 - 5. Doctor refused to access patient records
290948 - submitted electronically to VA and found
290949 - useful by primary care physician to make an
290950 - electronic referral for efficient notice of
290951 - requirement for eye examination; but, doctor
290952 - performing eye examination would not rely
290953 - on same electronic record for effecient,
290954 - accurate understanding on scope of
290955 - the problem........................ 070221 0819, ref SDS 4 BM47
290956 -
290958 - ..
290959 - Research on the Internet finds...
290960 -
290961 - [On 100709 1130 additional research shows more authorities
290962 - report VA has the best medical quality of care, attributed
290963 - in part to more efficient case management using computers
290964 - to manage the record. ref SDS 11 PR5H
290965 -
290967 - ..
290968 - VA Electronic Medical Record System EMR Improves Quality Patient Care
290969 -
290971 - ..
290972 - 1. Department of Veterans Affairs
290973 -
290974 - Medical Journal Praises VA Electronic Health Record
290975 -
290976 - April 6, 2009
290977 -
290978 - http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1662
290979 -
290980 - 1. VA Continues to Lead Health Care Industry
290981 -
290982 - WASHINGTON - A recent study in the prestigious New England
290983 - Journal of Medicine singles out the Department of Veterans
290984 - Affairs (VA) for its successful implementation of a
290985 - comprehensive system of electronic health records.
290987 - ..
290988 - On 050520 1045, Kaiser began using EMR systems for patient medical
290989 - chart/Progress Notes. ref SDS 2 HX6J
290990 -
290991 - [On 100709 1130 additional research shows more authorities
290992 - report VA has the best medical quality of care, attributed
290993 - in part to more efficient case management using computers
290994 - to manage the record. ref SDS 11 PR5H
290996 - ..
290997 - [On 100928 0706 received patient history on CABG +4 and
290998 - esophageal (Heller Myotomy) surgeries from the VA using
290999 - electronic medical records. ref SDS 13 U94I
291001 - ..
291002 - Article continues...
291003 -
291004 - 2. The study's authors, led by Dr Ashish K Jha of Harvard
291005 - University, noted that VA's use of electronic health
291006 - records has significantly enhanced the quality of patient
291007 - care. They also found that only 1.5 percent of U.S.
291008 - hospitals have comprehensive electronic health records;
291009 - adding VA hospitals to the analyses doubled that number.
291011 - ..
291012 - 3. "VA hospitals have used electronic health records for more
291013 - than a decade with dramatic associated improvements in
291014 - clinical quality," the study's authors wrote.
291016 - ..
291017 - 4. VA clinicians began using computerized patient records in
291018 - the mid-1990s for everything from recording examinations by
291019 - doctors to displaying results of lab tests and x-rays.
291020 - Patient records are available 100 percent of the time to VA
291021 - health care workers, compared to 60 percent when VA relied
291022 - on paper records.
291024 - ..
291025 - VA credited for advanced and comprehensive use of electronic medical
291026 - records (EMR) system compared to Kaiser, reported last week with links
291027 - to examples, on 091106 1000. ref SDS 9 VT6M
291028 -
291029 - [On 091119 1000 VA Medical Center in San Francisco could
291030 - not access server in Sacramento for results of lab
291031 - performed at VA in Martinez Clinic. ref SDS 10 9S5F
291033 - ..
291034 - 5. Dr Michael J Kussman, VA's under secretary for health,
291035 - said VA has "one of the most comprehensive and
291036 - sophisticated electronic systems" for patient records in
291037 - the nation.
291039 - ..
291040 - 6. "VA's electronic health record system has largely
291041 - eliminated errors stemming from lost or incomplete medical
291042 - records, making us one of the safest systems in the health
291043 - care industry," Kussman said.
291045 - ..
291046 - Compare VA errors delaying care for achalasia 5 years, reported in
291047 - case study on 090908 1130, ref SDS 5 FT6M; with case study of medical
291048 - mistakes at Kaiser treating Millie's stage V cancer as a chronic
291049 - disease for nearly 10 years, shown on 040416 1045. ref SDS 1 GN7J
291050 -
291051 - [On 150322 0444 article in New York Times with title
291052 - "Why Health Care Tech Is Still So Bad" complains about
291053 - lack of simulators to test and train doctors using
291054 - computers for electronic medical records systems -
291055 - evidently unaware of work at VA on this capability.
291056 - ref SDS 15 J178
291058 - ..
291059 - 7. The authors of the NEJM article are the latest to praise VA
291060 - for its technology and commitment to patient safety. In
291061 - 2006, VA received the prestigious "Innovations in American
291062 - Government" Award from Harvard's Kennedy School of
291063 - Government for its advanced electronic health records and
291064 - performance measurement system.
291066 - ..
291067 - VA credited for strong collaboration and coordination through
291068 - doctor/patient partnership, aided by advanced and comprehensive use of
291069 - electronic medical records (EMR) system that leverages teamwork for
291070 - optimizing outcomes, reported last week with links to examples, on
291071 - 091106 1000. ref SDS 9 I15I
291072 -
291073 -
291074 -
291075 -
291076 -
2911 -
SUBJECTS
VA $20 Billion Pioneer Electronic Medical Records EMR Case Managemen
5003 -
500401 - ..
500402 - Another article on the Internet reports...
500403 -
500404 - 2. Wall Street Journal....... wsj.com
500406 - ..
500407 - The Digital Pioneer Veterans hospitals have already fought this battle
500408 - -- and offer plenty of lessons on how it can be done
500409 - ----------------------------------------------------
500410 - by Jane Zhang
500412 - ..
500413 - October 27, 2009
500414 -
500415 - http://online.wsj.com/article/SB10001424052970204488304574428750133812262.html
500417 - ..
500418 - 1. As health-care providers gear up for a digital overhaul, they
500419 - could learn important lessons from an early innovator in the
500420 - field-veterans hospitals.
500422 - ..
500423 - 2. The government is spending nearly $20 billion in stimulus
500424 - funding to help hospitals and doctors switch to digitized
500425 - records, and Medicare will start penalizing those who don't
500426 - use them in a meaningful way by 2015. The goal is to boost the
500427 - quality of care and slash costs by keeping better track of
500428 - patients.
500430 - ..
500431 - 3. But the Department of Veterans Affairs made that digital
500432 - switch years ago-with striking results. Independent studies
500433 - show that the VA system does better on many measures,
500434 - especially preventive services and chronic care, than the
500435 - private sector and Medicare. VA officials say its technology
500436 - has helped cut down hospitalizations and helped patients live
500437 - longer.
500439 - ..
500440 - 4. Even though the sprawling health-care industry faces lots of
500441 - challenges as it goes digital, advocates say that the VA's
500442 - experience shows the technology, combined with quality
500443 - measurements, can work on a large scale.
500445 - ..
500446 - 5. The records system, which also delivers an easy way to track
500447 - physician performance, has been a boon to patients, says
500448 - Ashish Jha, associate professor of health policy at the
500449 - Harvard School of Public Health and a staff physician at the
500450 - VA hospital in Boston. Over the years, he says, "quality goes
500451 - up, but cost stays flat, compared to the rest of the country."
500452 -
500454 - ..
500455 - Alerts Notices Automatically Generated VA Electronic Medical Records EMR System
500456 -
500457 -
500458 - 6. Healthy and Efficient
500459 -
500460 - The VA's system allows doctors and nurses at more than 1,400
500461 - facilities to share a patient's history, which means they can
500462 - avoid ordering repeat MRIs or other unnecessary tests. But the
500463 - system isn't just a warehouse to store patient data. More
500464 - important, it has safeguards to improve care quality. The
500465 - system warns providers, for example, if a patient's blood
500466 - pressure goes beyond a targeted level, or if he or she is due
500467 - for a flu shot or cancer screening.
500469 - ..
500470 - [On 110218 0730 Iris, lead nurse in GI Department for VA
500471 - Martinez advised that patient medical records for
500472 - Advance Directive signed on 091023, file in the San
500473 - Francisco Medical Center reported on 100928, ref SDS 13
500474 - PQ5R, is not available to the VA Clinic in Martinez.
500475 - ref SDS 14 EE4L
500477 - ..
500478 - 7. It also helps the VA monitor patient care at home, especially
500479 - for people with complex, chronic illnesses, such as diabetes
500480 - and heart failure. The VA gives those patients special gadgets
500481 - free of charge to measure weight, heart rates, blood pressure
500482 - and other conditions, and the daily results are automatically
500483 - transmitted into the VA's medical-record system, says
500484 - cardiologist Ross Fletcher, chief of staff at the VA medical
500485 - center in Washington. If the numbers exceed target levels, a
500486 - nurse is notified.
500488 - ..
500489 - 8. Dr Fletcher recently pulled up the record of a 59-year-old man
500490 - from Maryland for a demonstration. The record listed his
500491 - health problems, such as hypertension and diabetes, and data
500492 - for his weight and blood pressure since he first became a
500493 - patient at the VA. The doctor could also open digital images
500494 - of the patient's past X-rays, lab results and other materials,
500495 - and zoom in for details.
500497 - ..
500498 - 9. A reminder also popped up, warning Dr Fletcher that the
500499 - patient's blood-sugar control level was above 8%, according to
500500 - a home-measurement device and a test at the clinic. The
500501 - reminder will stay there for all providers in the system to see
500502 - until the patient brings it below 8%. He also has other
500503 - services due, such as a flu vaccine. Before the appointment,
500504 - he'll get a reminder call-and if he misses the visit, he'll get
500505 - a call to reschedule it.
500507 - ..
500508 - 10. Also on the screen: a list of the patient's medications,
500509 - including insulin, the pain medication Oxycodone and
500510 - heart-failure drug Furosemide. Dr. Fletcher can reorder a drug
500511 - through the system and have the request show up at the
500512 - pharmacy; the patient can also order refills through an online
500513 - portal. And if the doctor orders a new medication that
500514 - interferes with something the patient is already taking, a
500515 - warning pops up.
500516 - Higher Quality
500518 - ..
500519 - Hospital Admissions Reduced 25% Length of Stay Reduced 20%
500520 -
500521 -
500522 - 11. The VA says the system has brought dramatic improvements.
500523 - Consider the VA's in-home monitoring program, which has about
500524 - 40,000 patients enrolled. The VA says the program has reduced
500525 - hospital admissions by 25% and length of hospital stay by 20%.
500526 - The system's automated reminders have also boosted performance
500527 - in many areas. For example, the percent of patients receiving
500528 - a flu vaccine rose to 83% last year from 27% in 1995, says
500529 - Fernando Rivera, the Washington VA hospital's medical
500530 - director. Colon-cancer screenings increased to 84% from 34%
500531 - during the same period.
500533 - ..
500534 - Errors Reduced on Medications
500535 -
500536 -
500537 - 12. What's more, the VA says it has reduced medication errors
500538 - significantly since it introduced a scanning system in 1999.
500539 - It requires nurses to scan tags for patients and medications
500540 - to ensure that they are giving the right medication to the
500541 - right patient at the right dose and time.
500543 - ..
500544 - 13. Patients notice the difference. When Dwayne Thompson went for
500545 - a physical last month at the veterans hospital in Baltimore,
500546 - he didn't have to fill out any paperwork. He checked in for
500547 - the appointment using his last name and part of his Social
500548 - Security number, and waited less than 20 minutes before he was
500549 - called for a blood sample, a visit with a social worker and an
500550 - ankle X-ray-which was immediately fed into the hospital's
500551 - electronic health records.
500552 -
500553 - 14. "The process was effortless," says Mr Thompson, a 42-year-old
500554 - Persian Gulf veteran in Baltimore. "They seemed to have
500555 - everything in order."
500556 -
500558 - ..
500559 - VA Leading Health Care Provider Only 1.5% Private Sector Hospitals Use EMR
500560 -
500561 -
500562 - 15. The situation at the VA stands in stark contrast to the
500563 - rest of the nation's health-care system. Only 1.5% of US
500564 - hospitals nationwide have a comprehensive digital-record
500565 - system, let alone share information among different
500566 - providers, according to a recent study co-authored by Dr
500567 - Jha in the New England Journal of Medicine.
500568 -
500570 - ..
500571 - VA Care for Life Business Model Contrasts Private Sector Hospitals
500572 -
500573 -
500574 - 16. To be sure, the VA's health-care system isn't a perfect
500575 - roadmap for the industry-since the agency is in a unique
500576 - position. The VA, through the Veterans Health
500577 - Administration, employs the doctors, nurses and other
500578 - health workers, which makes it easier to mandate
500579 - performance standards. The VA also has an incentive to
500580 - keep patients healthier because it takes care of veterans
500581 - for life and sicker patients eat up the VA's budget faster.
500582 - (Indeed, some veterans have trouble getting into the system
500583 - partly because of the VA's budget limitations.) Elsewhere,
500584 - most doctors and hospitals work independently, making it
500585 - harder to monitor patient care. And those providers are
500586 - rewarded for simply providing more care, not high-quality
500587 - care.
500589 - ..
500590 - 17. Still, there are signs that private providers are taking
500591 - lessons from the VA. In fact, some hospitals are adapting
500592 - the VA's record system, VistA, for commercial use. (Some
500593 - applications of the software, which was developed by the
500594 - government, are available free.)
500596 - ..
500597 - VA Serves 8 Million Patients with 1100 Hospitals and Clinics Nationwide
500598 -
500599 -
500600 - 18. The VA turned to electronic records out of necessity. It
500601 - serves 7.84 million patients through 153 hospitals, 765
500602 - outpatient clinics and 230 veterans centers and other
500603 - facilities, and many patients are seen at different
500604 - facilities. The Washington VA hospital alone used to have
500605 - between 4,000 and 5,000 folders, not including imaging files,
500606 - and sometimes they got lost during file transfers, Mr Rivera
500607 - says. Now the storage room is used as office space.
500609 - ..
500610 - 19. The VA started developing the VistA system in the 1970s, and
500611 - began sharing lab results and medication information in the
500612 - 1980s, says Dr. Fletcher, who was involved in the development
500613 - process. The system got a major upgrade in the mid-1990s, when
500614 - it became easy to use for doctors and nurses, and added
500615 - clinical reminders and other quality measures.
500617 - ..
500618 - 20. One of the next big steps for the system is allowing doctors
500619 - to see information about patient care received outside of the
500620 - VA, since most VA patients also use other health-care
500621 - providers.
500623 - ..
500624 - 21. Already, the VA and the Defense Department are sharing
500625 - information on 3.4 million patients treated both at the VA and
500626 - military facilities, says Chuck Campbell, chief information
500627 - officer for the Military Health System. In addition, he says,
500628 - the department has collected information on 4.8 million
500629 - patients from its various electronic systems since 2002 and
500630 - forwarded it to the VA once they were discharged.
500632 - ..
500633 - 22. In January, the two systems and a private managed-care
500634 - company, Kaiser Permanente in San Diego, plan to test a pilot
500635 - on how to share information on patients seen by the three
500636 - systems. If successful, it will be expanded to other insurers.
500638 - ..
500639 - 23. Mr Campbell sees the test run as a harbinger of things to come.
500640 - Once everyone uses the same standard for digital records, he
500641 - says, "you can share information easily across the nation."
500643 - ..
500644 - 24. - Ms. Zhang is a staff reporter in The Wall Street Journal's
500645 - Washington, D.C., bureau. She can be reached at
500646 - jane.zhang@wsj.com.
500647 -
500648 -
500649 -
500650 -
5007 -
SUBJECTS
Default Null Subject Account for Blank Record
5103 -
510401 - ..
510402 - Another article reports difficulty implementing VA's electronic
510403 - medical records (EMR) system, ref SDS 0 W45P, benefits of the system
510404 - for making sense of complex patient history, ref SDS 0 XG38, and using
510405 - computer simulators to test new software and train doctors and nurses
510406 - using computers for efficient, accurate case management. ref SDS 0
510407 - KB5H
510409 - ..
510410 - 3. IEEEXPLORE Digital Library
510411 -
510412 - System Sciences (HICSS), 2010 43rd Hawaii International
510413 - Conference on
510415 - ..
510416 - Issue Date: 5-8 Jan. 2010
510417 - On page(s): 1 - 9
510418 - Location: Honolulu, HI
510419 - ISSN: 1530-1605
510420 - Print ISBN: 978-1-4244-5509-6
510421 - INSPEC Accession Number: 11205965
510422 - Digital Object Identifier: 10.1109/HICSS.2010.145
510423 - Date of Current Version: 11 March 2010
510425 - ..
510426 - Developing an EMR Simulator to Assess Users' Perception of Document Quality
510427 -
510428 - Date of Current Version: 11 March 2010
510429 -
510430 - http://ieeexplore.ieee.org/Xplore/login.jsp?url=http%3A%2F%2Fieeexplore.ieee.org%2Fiel5%2F5428222%2F5428274%2F05428389.pdf%3Farnumber%3D5428389&authDecision=-203
510432 - ..
510433 - Background on IEEE Xplore scholarly research database indexes,
510434 - abstracts, and provides full-text for articles and papers on computer
510435 - science, electrical engineering and electronics. Database contains
510436 - some of the world's most highly cited publications in electrical
510437 - engineering, computer science and electronics....
510438 -
510439 - http://en.wikipedia.org/wiki/IEEE_Xplore
510441 - ..
510442 - Paper Developing EMR Simulator... continues...
510443 -
510444 - Efthimis N Efthimiadia, PhD,....... efthimis@u.washington.edu
510445 - Kenric W Hammond, MD............... kenric.hammond@va.gov
510446 - Ryan Laundry
510447 - Stephen M Thielke, MD
510449 - ..
510450 - Information School, University of Washington, Seattle, WA
510452 - ..
510453 - VA Pugent Sound Health Care System, Tacoma and Seattle, WA
510455 - ..
510456 - Abstract
510458 - ..
510459 - Simulators are used in research and training because they
510460 - provide a realistic and safe environment for participants. In
510461 - the course of conducting a comprehensive study of patient care
510462 - documentation in electronic medical record (EMR) systems we
510463 - found that use of a simulated EMR system could address logistic
510464 - and conceptual barriers encountered in deploying a research
510465 - instrument to assess user perceptions of patient care document
510466 - quality. Designed for use by practitioners, nurses, and
510467 - administrators at four VA hospital sites, the web-based EMR
510468 - simulator presents clinical documents as they appear in VA's
510469 - CPRS production EMR, and administers a document quality
510470 - assessment questionnaire. The EMR simulator was developed to
510471 - overcome the contradiction of studying computerized documents
510472 - with a paper instrument, to permit self-administration at
510473 - multiple sites and to manage data collection. This paper
510474 - discusses the motivation to evaluate EMR document quality,
510475 - development of the quality questionnaire, and how the design of
510476 - the simulator evolved and was pilot tested.
510477 -
510478 - [On 150322 0444 article in New York Times with title
510479 - "Why Health Care Tech Is Still So Bad" complains about
510480 - lack of simulators to test and train doctors using
510481 - computers for electronic medical records systems -
510482 - evidently unaware of work at VA on this capability.
510483 - ref SDS 15 J178
510485 - ..
510486 - 1. Introduction
510487 -
510488 - Adoption of electronic medical records (EMRs) is at the
510489 - center of national health care reform strategy. The EMR
510490 - furnishes health care personnel with patient data captured
510491 - by health care information systems (HCIS). Its primary
510492 - function is to support health care decision-making by
510493 - serving as the point of contact between human minds and the
510494 - complete medical data stored in a HCIS. It provides a
510495 - "viewing window" for information access and a "transaction
510496 - window" for conducting health care business. The EMR
510497 - interface should present the "right" amount of information
510498 - to users. Otherwise there is risk of information overload
510499 - and "overlook" of important information that could lead to
510500 - degradation of decision quality{1}.
510502 - ..
510503 - Decision-making is a central cognitive activity for EMR
510504 - users. Many aspects of physician decision-making (e.g.,
510505 - problem formulation, diagnosis, and choice of therapy and
510506 - tests) have been described from a formal logical
510507 - perspective {2}. Also important, for physicians, nurses
510508 - and administrative staff alike, is naturalistic
510509 - decision-making {2}, and emerging area of cognitive study
510510 - which recognizes that expert decisions are frequently based
510511 - on pattern recognition and situation awareness rather than
510512 - formal logic. Both modes of decisoin making can be
510513 - supported by the EMR, Rule-based decision making requires
510514 - "facts" from the EMR: labs, demographics, studies and
510515 - events. Naturalistic decison making relies on decisions
510516 - cued by patterns of facts, many of which are expressed in
510517 - the narrative text that is written by the clinicians,
510518 - doctors or nurses, during patient care and found in notes,
510519 - reports and summaries in the EMR. In both cases, decision
510520 - making based on an electronic patient chart becomes
510521 - increasingly complex as the volume of data in the HCIS
510522 - increases {4}. Data display strategies that work
510523 - reasonably well with sparse data may fail when data is
510524 - abundant. Coping with the growth of data in successfully
510525 - implemented EMR systems is an emerging cognitive challenge
510526 - for EMR users.
510527 -
510528 -
510530 - ..
510531 - We use the term computerized patient care documentation
510532 - (CPD) to refer to the free text progress notes,
510533 - consultation reports and summaries that reside in the
510534 - electronic medical record. Free text narrative is signed
510535 - by an author and is an official legal document.
510536 - Categorical, numeric and image data (e.g., coded diagnoses,
510537 - lab reports, prescriptions, appointments, bills and x-rays)
510538 - are excluded. CPD is an important but problematic EMR
510539 - information resource: while it can vividly and succinctly
510540 - tell a patient's "story", clinical text in contrast to
510541 - published text is often hurriedly created, highly variable,
510542 - unedited, unstructured and voluminous. This poses a
510543 - significant challenge to the health care worker whose
510544 - decisions depend on an effective interpretation and
510545 - response to CPD text. Preliminary investigations of the US
510546 - Department of Veterans Affairs' (VA's) computerized patient
510547 - record system (CPRS) have revealed important quality
510548 - concerns that organizations adopting EMRs will face when
510549 - they fully implement electronic documentation. These
510550 - include the "copy and paste" phenomenon, poor formatting,
510551 - clutter, and propagation of inaccuracy {5-7}. Each of
510552 - these can negatively impact safety and human performance.
510554 - ..
510555 - To date, most studies of the impact of documetnation on
510556 - work activity in an EMR have relied on observations and
510557 - self-report. Paper-based study methods fail toreplicate
510558 - the computer experience, and practical and ethical
510559 - considerations (privacy, safety, time and cost) limit
510560 - controlled experimentation in production EMR systems.
510562 - ..
510563 - Given realistic data and EMR interfaces studies involving
510564 - EMR document review could be conducted without disrupting
510565 - operations. Because simulators provide a realistic and
510566 - safe environment for participants, they are useful in
510567 - research and training. The desire for a flexible,
510568 - non-disruptive experimental approach motivated the effort
510569 - to develop a simulated EMR testing platform capable of
510570 - presenting real patient data, and equipping it with
510571 - measurement tools such as questionaires, exercises and
510572 - timers. Also desirable was a method that could be applied
510573 - at muliple research sites, scheduled at staff convenience,
510574 - and conducted in the workplace. These considerations
510575 - shaped the decison to build a web-based system that could
510576 - eventually permit large scale interface testing involveing
510577 - many users at hundreds of worksites in the VA health care
510578 - network.
510580 - ..
510581 - This paper focuses on design issues surrounding the
510582 - development of the simulator. First we present the
510583 - conceptual foundations and the motivation for the
510584 - simulator. Then in section 2, we provide background
510585 - information regarding CPRS, the VA's EMR and in section 3
510586 - describe the large study that the simulator supports. In
510587 - section 4 we present the design methodology, and in section
510588 - 5 provide a descriptive technical overview of the
510589 - simulator. Discussion of the pilot tests and concluding
510590 - remarks follow.
510592 - ..
510593 - 1.1 Conceptual Foundations and Motivation
510595 - ..
510596 - This work is part of a larger VA Health Services Research
510597 - and Development effort to better understand and improve EMR
510598 - documentation: identifying problems, sources of problems
510599 - and possible solutions from the EMR user's perspective. As
510600 - part of theoverall goal of understanding threats to
510601 - accuracy and efficient processing of documetn-based
510602 - information in health care, it was felt necessary to defin,
510603 - quantify and validate a concept of "information value" in
510604 - clinical documents. Recognizing that CpD is not the
510605 - exclusive providne of any single work role in a health care
510606 - system, we chose a user-centered approach, and conducted
510607 - focus group interviews of practitioners, administrators and
510608 - nurses to understand their experience with the CPD system
510609 - and to elicit user-oriented concepts of document quality
510610 - from a multi-role perspective. Using this information we
510611 - developed and refined a document quality questionaire.
510612 - Then, we developed a simulated EMR system to present the
510613 - questionaire. The research process is summarized by the
510614 - following steps:
510615 -
510616 - ......
510618 - ..
510619 - 2. Background
510620 -
510621 - 1. CPRS 0 the VA's successful EMR
510622 -
510623 - The VA's EMR development effort began in 1977 {9}.
510624 - In 2982, the VA nationally adopted a system that
510625 - supported administrative, lab, and pharmacy
510626 - operations and had some basic EMR functions. In
510627 - 1977, the system implemented a graphical user
510628 - interface. The on-screen presentation of the CPRS
510629 - was deliberately fashioned to resembel a
510630 - traditional chart, with tabbed sections for labs,
510631 - orders, notes, consults, etc. VA hospitals started
510632 - becoming "paperless" in 1999. By 2002 all 162 VA
510633 - hospitals were paperless and the system was
510634 - networked, permitting remote access to data between
510635 - all VA facilities.
510637 - ..
510638 - The graphical CPRS interface improved access to a
510639 - wide range of patient information {10} and
510640 - databases accrued from clinical operations both
510641 - provide a rich resource for research and drive the
510642 - VA's quality improvmeent {11-13}. VA's CpRS is
510643 - promoted as a model for other health care
510644 - organizations {14}, but CPRS users have also
510645 - experienced unwelcome consequences of its success,
510646 - notably information volume overload and input
510647 - burden.
510649 - ..
510650 - 2. Beginning around the year 2000 and counterbalancing
510651 - projections that new technology would save lives
510652 - and money {15,16} several investigators described
510653 - unforseen adverse consequences of introducing
510654 - health care information systems (HCIS) and EMRs.
510655 - These included increases in errors seen with
510656 - introduction of the HCIS {17-19}, problems with
510657 - documentation {5,6,20,21}, and even outright
510658 - rejection of the EMR by clinicians {22,23}. A
510659 - growing realization arose that existing information
510660 - systems fail to accomodate teh "complex
510661 - socio-technical systems" of health care.
510663 - ..
510664 - A recent report to the National Research Council
510665 - (NCR) commissioned by the National Library of
510666 - Medicine makes a similar critique. Its authors,
510667 - informatics experts who surveyed eight leading HCIS
510668 - systems, concludde that these systems {24}:
510669 -
510670 - 1. appear designed largely to automate tasks or
510671 - business processes
510673 - ..
510674 - 2. are designed in ways that simply mimic existing
510675 - paper-based forms
510677 - ..
510678 - 3. provide little support for the cognitive tasks
510679 - of clincians or the workflow of the people who
510680 - must actually use the system.
510682 - ..
510683 - 4. do not utilize human-computer interaction (HCI)
510684 - principles, leading to poor designs that can
510686 - ..
510687 - increase the chance of error
510688 - add to work load
510689 - compound frustrations completing tasks
510690 - cause new forms of error difficult to detect
510692 - ..
510693 - The NCR report also described insufficient support for
510694 - clinical cognition as a key challenge in present day
510695 - EMR systems {24}.
510697 - ..
510698 - 3. Prior work
510699 -
510700 - Our ongoing research project, VA Health Services
510701 - Research and Development project IIR 05-019, studies
510702 - the CPRS documetation system and how VA employees work
510703 - with it. As part of this study, we conducted 14
510704 - scripted focus groups at four VA sites, interviewing
510705 - 129 VA practitioners, nurses and administrative
510706 - personnel in 2007 and 2008. CPRS users gave examples
510707 - of the challenge they faced when navigating and working
510708 - in the large "information space" of clinical
510709 - documentation. A recurring theme was the EMR's
510710 - inabiity to present document information in ways that
510711 - were a good "cognitive fit" with tasks. Too often, the
510712 - information user's needed to complete their work was
510713 - scattered in different screens, or so combined with
510714 - irrelevant information that users were slowed down and
510715 - frustrated. Participants said they knew that the
510716 - information they needed was present in the HCIS, but
510717 - were stymied when it was hard to find or when access to
510718 - information needed to complete a transaction was
510719 - blocked. Other frequent themes included: poor support
510720 - for communication between memebers of the care team;
510721 - distress and irritation when copy-and-paste (which
510722 - users also stated they were driven to use by time
510723 - pressure) impeded use of the written record; and
510724 - suboptimal support for the information needs of ward
510725 - nurses. {25,26}. Themes from focus groups were
510726 - distilled to four major categories: (1) irrelevant and
510727 - redundant textual data, (2) difficulty with copied and
510728 - pasted test, (3) awkward navigation and (4) poor fit
510729 - with inpatient work.
510730 -
510731 - [On 100911 0800 discussion on flight from JFK to
510732 - SFO, with VA doctor; patient credits VA for
510733 - improving speed of access to computer records; VA
510734 - doctor cited "Knowledge Management loop" that
510735 - redundancy and ignoring the record collapses
510736 - productivity and vitiates care because doctors and
510737 - nurses do not have command and control of the record
510738 - on patient history, ref SDS 12 OL50, citing case
510739 - study of work at VA on 091021. ref SDS 6 FB5N
510741 - ..
510742 - [On 150322 0444 article in New York Times with title
510743 - "Why Health Care Tech Is Still So Bad" complains
510744 - about lack of simulators to test and train doctors
510745 - using computers for electronic medical records
510746 - systems - evidently unaware of work at VA on this
510747 - capability. ref SDS 15 J178
510749 - ..
510750 - The focus interviews revealed that VA users experienced
510751 - many benefits from CPRS. They cited CPRS as a reason
510752 - they liked working at the VA. They valued computerized
510753 - documentation because narrative helped "make sense" of
510754 - other data in the EMR. Because users reported
510755 - furstrations, stress and time pressure in their work
510756 - with CPRS, we anticipated their support in efforts to
510757 - improve the system's efficiency.
510759 - ..
510760 - Accordingly, we undertook to investigate document
510761 - review, and activity common to all users studied, and
510762 - in this instance, examined the impact of documetns
510763 - containing greater or lesser amounts of boilerplate and
510764 - inserted data (factors frequently cited by our subjects
510765 - as contributing to document "clutter"). Future studies
510766 - will explore specific enhancement strategies to
510767 - overcome other identified barriers. Use of a simulator
510768 - will permit experimental evaluation in realistic work
510769 - contexts.
510770 -
510771 -
510772 -
510773 -
510774 -
510775 -
510776 -
510777 -
510778 -
510779 -
510780 -
5108 -