Design and Evaluation of User Centered Electronic Health Records

描述(由申请人提供)： 到目前为止，很少有关于提供者如何在真实的临床环境中使用电子健康记录(EHR)系统的定量研究，以及评估EHR可用性的方法和指标：用户可以实现预期任务的有效性、效率和满意度。这样的研究可以确定重新设计的候选部件。特别是，记录患者的遭遇和现有患者数据的信息检索是护理点临床工作流程的补充任务。文档通常以叙事形式存储为非结构化文本文档。提供商还从以前的笔记中检索信息。缺乏电子病历自动化和糟糕的用户界面可能会导致将冗余信息引入患者记录(例如，从电子病历的其他区域复制/粘贴的信息)以及低效的工作流程，例如当临床医生通过结构化菜单输入订单并随后在进度记录中手动记录这些订单时导致的重复工作。在我们之前对门诊环境下的时间运动研究(PACE研究)中，我们发现：(1)在有限的办公室会诊时间框架内，电子病历工作流程效率低下。这些可归类为：(A)导航：提供者跨屏幕移动以检索分散的患者信息，然后在精神上整合；(B)订单录入：由嵌套下拉菜单和其他低效界面驱动，以及(C)文档：笔记包含从早期笔记或电子病历的其他部分复制/粘贴的冗余信息，输入的订单的重复文档，难以搜索的笔记，以及生成样板的模板。(2)CPRS/Vista备注功能约占整个EHR活动的一半，是活动的中心纽带，因为供应商反复导航回备注以供参考(根据任务时间、鼠标活动和导航模式，备注和订单录入任务合计占工作流活动的20%~75%)。因此，Notes是一个很有前途的重新设计的候选软件。(3)我们观察到供应商的电子病历工作流程和他们在进度说明中组织信息的方式存在很大差异，这值得进一步研究。拟议的项目有3个具体目标：(1)纵向测量患者记录中随着时间的推移引入的冗余程度(主要结果衡量标准)，并执行基线内容分析，以研究临床医生如何将他们的笔记组织和分割成主要部分(如肥皂)的变化。我们还将研究不同提供商之间的词汇和术语差异。这一目标是基于两个退伍军人事务部网站的序列比对和手工编码的时间索引的CPRS/Vista进展说明。临床医生访谈(刺激回忆)将为研究结果提供背景信息。(2)定量描述初级保健提供者如何使用 备注和用于文件和信息检索任务的电子病历(例如，备注的哪些组成部分是供应商新输入的、复制/粘贴的或样板？提供者可以访问哪些EHR组件来获取导入到Notes中的现有患者数据元素？)这一目标是基于为我们在退伍军人事务部一个地点进行的PACE研究而捕获的现有时间运动数据。(3)开发和评估ActiveNotes软件系统，以便在护理点提供更可用的文件和订单录入系统。ActiveNotes是一个由VHA赞助的项目(hi2倡议)。ActiveNotes是一个增强的文本编辑器，它使用基于解析器的技术堆栈来解释临床医生的输入。ActiveNotes使用动态布局和超链接来减少冗余信息，并优化结构化和非结构化EHR数据的文档和信息检索任务。原型的形成性可用性评估将被迭代并集成到敏捷开发过程中。临床医生最终用户基于测试数据的反馈，以及来自其他利益相关者的输入，将指导系统设计决策。

DESCRIPTION (provided by applicant): To date, there is little quantitative research on how providers use Electronic Health Record (EHR) systems in real clinical settings, and on the methodology and metrics to assess EHR usability: the effectiveness, efficiency, and satisfaction with which users can achieve intended tasks. Such research can identify candidate components for redesign. In particular, documentation of the patient encounter and information retrieval of existing patient data are complementary tasks of the clinical workflow at the point of care. Documentation is often in narrative form stored as unstructured text documents. Providers also retrieve information from previous notes. Lack of EHR automation and poor user interfaces can contribute to the introduction of redundant information into the patient record (eg, information copy/pasted from other areas of the EHR) as well as to inefficient workflows such as the duplicative work that results when clinicians enter orders through structured menus and subsequently manually document these orders in progress notes. In our previous research on time-motion studies in an outpatient setting (PACE study), we found the following: (1) inefficiencies in EHR workflow during the constrained time frame of office consultations. These can be classified as resulting from (a) navigation: providers move across screens to retrieve and then mentally integrate scattered patient information; (b) order entry: driven by nested pull-down menus and other inefficient interfaces, and (c) documentation: notes contain redundant information copy/pasted from earlier notes or other parts of the EHR, duplicative documentation of orders entered, poorly searchable notes, and boilerplate- generating templates. These contribute to information being lost in a "sea of text." (2) The CPRS/VistA Notes function accounts for about half of total EHR activity and is quantifiably a central nexus of activity because providers repeatedly navigate back to Notes for reference (together, Notes and order entry tasks account for 20 ~75% of workflow activity, based on time-at-task, mouse activity and navigation patterns). Therefore, Notes is a promising candidate for redesign. (3) We observed wide variation in providers' EHR workflow and in how they organize information in progress notes, which deserves further study. The proposed project has 3 specific aims: (1) To measure longitudinally the degree of redundancy (primary outcome measure) introduced over time in patient documentation, and to perform baseline content analysis to study variation in how clinicians organize and segment their notes into major sections (eg, SOAP). We will also study lexical and terminology variation across providers. This aim is based on sequence alignment and manual coding of time-indexed archival CPRS/VistA progress notes from two VA sites. Clinician interviews (Stimulated Recall) will provide context for the findings. (2) To quantitatively profile how primary care providers use Notes and the EHR for documentation and information retrieval tasks (eg, which components of the note are newly entered by providers, copy/pasted, or boilerplate? What EHR components do providers access to source existing patient data elements imported in Notes?). This aim is based on existing time-motion data captured for our PACE study at one VA site. (3) To develop and evaluate the ActiveNotes software systems for more usable documentation and order entry system at the point of care. ActiveNotes is a VHA-sponsored project (hi2 initiative). ActiveNotes is an enhanced text editor that uses a technology stack based on parsers to interpret clinicians' input. ActiveNotes uses dynamic layout and hyperlinking to reduce redundant information and optimize documentation and information retrieval tasks of both structured and unstructured EHR data. Formative usability evaluation of prototypes will be iterative and integrated into the Agile development process. Feedback from clinician end-users based on test data, as well as input from other stakeholders, will guide system design decisions.