Assessing the Effect of Telemedicine on Physician EHR Work, Cognition, and Process Outcomes (ASPIRE)

项目摘要 2019冠状病毒病（COVID-19）大流行以持续的方式极大地改变了医疗保健服务。 为了遵守物理距离准则并提供患者护理的连续性， 流动医疗的主要模式，以远程医疗为基础的虚拟遭遇。这种转变改变了 病人护理结构、管理和提供--对病人--提供者有很大的潜在变化 沟通和临床信息的可用性。例如，在远程医疗遇到临床医生 不能再进行身体检查或获取生命体征，从而为临床推理和决策提供信息， 常规门诊评估和管理（E&M）。反过来，这些因素可能有助于 临床不确定性，从而改变临床医生如何利用电子健康记录（EHR）。他们可能 需要进行额外的病历审查，以填补信息空白，输入患者生成的健康数据，或发送 更多的后续通信。这些变化中的一个或多个有助于加强基于EHR的认知负荷 随着EHR活动和活动切换的增加，无论是在遭遇级别还是在整个过程中的累积 一个工作日。反过来，更大的基于EHR的认知负荷可能导致次优的临床决策（例如， 更多的诊断测试或转诊）和更多的错误（例如，病人的错误命令）。 在建议评估远程医疗对医生EHR工作，认知和过程的影响 结果（ASPIRE）项目，我们调查的主要假设，门诊远程医疗遇到的， COVID背景与临床医生和下游人员基于EHR认知负荷增加有关 次优的临床决策和更频繁的错误。我们利用新颖的，基于EHR的审计日志数据， 跨越前和COVID时期（2019年3月至2022年2月）的一年时间段，以直接测量临床医生的EHR 在两个大型学术医疗中心（华盛顿）开展远程医疗和面对面交流活动 圣刘易斯大学和加州大学旧金山弗朗西斯科分校）。利用COVID-19大流行作为一种自然的 该实验显着增加了门诊远程医疗服务（两个健康中心增加了25倍以上） 系统），我们的第一个目标将表征EHR为基础的活动之间的差异面对面， 远程医疗遭遇。然后，我们将构建EHR活动开关（内部和跨 遭遇）作为认知负荷的代理指标，并评估认知负荷对 临床决策和错误的病人错误。这些目标的结果将在我们的最终报告中得到利用。 “设计”的目的是使用一线临床医生访谈和国家专家eDelphi过程，以引出基于EHR的 影响远程医疗的因素，并确定潜在的设计策略，以解决相关的 挑战eDelphi过程将侧重于将已确定的设计策略转化为 务实的目标，以改善电子健康记录支持远程医疗的遭遇。

PROJECT SUMMARY The Coronavirus disease 2019 (COVID-19) pandemic dramatically altered healthcare delivery in persistent ways. To adhere to the physical distancing guidelines and to provide continuity of patient care, organizations shifted the primary modality of ambulatory care to telemedicine-based virtual encounters. This transition has altered the structure, management, and delivery of patient care—with large potential changes to patient-provider communication and availability of clinical information. For example, during telemedicine encounters clinicians can no longer conduct physical exams or obtain vitals that inform clinical reasoning and decision making in routine ambulatory evaluation and management (E&M) encounters. In turn, these factors may contribute to clinical uncertainty, and thereby alter how the clinician leverages the electronic health record (EHR). They may need to engage in additional chart review to fill information gaps, enter patient-generated health data, or send more follow-up communications. One or more of these changes serves to intensify EHR-based cognitive load as EHR activities and activity switching increase, both at the encounter level and cumulatively over the course of a workday. In turn, greater EHR-based cognitive load could contribute to suboptimal clinical decisions (e.g., more diagnostic tests or referrals) and more errors (e.g., wrong-patient orders). In the proposed Assessing the Effect of Telemedicine on Physician EHR Work, Cognition, and Process Outcomes (ASPIRE) project, we investigate the primary hypothesis that ambulatory telemedicine encounters in the COVID context are associated with increased EHR-based cognitive load among clinicians, and downstream suboptimal clinical decisions and more frequent errors. We leverage novel, EHR-based audit log data from a 3- year period spanning pre- and COVID-periods (March 2019 – February 2022) to directly measure clinicians' EHR activities in telemedicine and face-to-face encounters at two large academic medical centers (Washington University in St Louis and University of California, San Francisco). Using the COVID-19 pandemic as a natural experiment that dramatically increased ambulatory telemedicine encounters (more than 25-fold at the two health systems), our first aim will characterize the differences in EHR-based activities between face-to-face and telemedicine encounters. We will then construct a derivative measure of EHR activity switches (within and across encounters) as a proxy measure of cognitive load and evaluate the downstream impact of cognitive load on clinical decision making and wrong-patient errors. The findings from these aims will be leveraged in our final “design” aim that uses frontline clinician interviews and a national expert eDelphi process to elicit the EHR-based factors impacting telemedicine encounters and to identify potential design strategies to address associated challenges. The eDelphi process will focus on translating and prioritizing the identified design strategies into pragmatic goals to improve EHR support for telemedicine encounters.