A Multisite Survey Study of EMR Review Habits, Information Needs, and Display Preferences among Medical ICU Clinicians Evaluating New Patients

Nolan, Matthew E.; Cartin‐Ceba, Rodrigo; Moreno-Franco, Pablo; Pickering, Brian; Herasevich, Vitaly

doi:10.4338/aci-2017-04-ra-0060

Cited by 13 publications

(16 citation statements)

References 13 publications

(17 reference statements)

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“…As mentioned earlier, we first conducted a survey study about medical ICU chart review habits. 12 Comparing those findings to our observational results, users accurately estimated spending the most time reviewing clinical notes, although they estimated spending approximately 5 minutes longer performing chart review than we actually observed. Interestingly, they did not describe "miscellaneous"-type clinical notes as commonly useful, whereas we identified very frequent viewing of these notes in our actual observations.…”

Section: Context Of Other Studiessupporting

confidence: 58%

“…While existing research has evaluated some aspects of EHR information use and workflow in critical care, [6][7][8][9][10][11] detailed descriptions of these concepts could not be identified, particularly for unstructured/semistructured data like clinical notes. After conducting a preliminary survey study on the topic, 12 we identified the need for direct observation of clinician-EHR behavior to overcome limitations of recall bias and analyze specific workflow sequence, prompting the present study.…”

Section: Background and Significancementioning

confidence: 99%

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Health IT Usability Focus Section: Data Use and Navigation Patterns among Medical ICU Clinicians during Electronic Chart Review

et al. 2017

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Background A detailed understanding of electronic health record (EHR) workflow patterns and information use is necessary to inform user-centered design of critical care information systems. While developing a longitudinal medical record visualization tool to facilitate electronic chart review (ECR) for medical intensive care unit (MICU) clinicians, we found inadequate research on clinician–EHR interactions. Objective We systematically studied EHR information use and workflow among MICU clinicians to determine the optimal selection and display of core data for a revised EHR interface. Methods We conducted a direct observational study of MICU clinicians performing ECR for unfamiliar patients during their routine daily practice at an academic medical center. Using a customized manual data collection instrument, we unobtrusively recorded the content and sequence of EHR data reviewed by clinicians. Results We performed 32 ECR observations among 24 clinicians. The median (interquartile range [IQR]) chart review duration was 9.2 (7.3–14.7) minutes, with the largest time spent reviewing clinical notes (44.4%), laboratories (13.3%), imaging studies (11.7%), and searching/scrolling (9.4%). Historical vital sign and intake/output data were never viewed in 31% and 59% of observations, respectively. Clinical notes and diagnostic reports were browsed ≥10 years in time for 60% of ECR sessions. Clinicians viewed a median of 7 clinical notes, 2.5 imaging studies, and 1.5 diagnostic studies, typically referencing a select few subtypes. Clinicians browsed a median (IQR) of 26.5 (22.5–37.25) data screens to complete their ECR, demonstrating high variability in navigation patterns and frequent back-and-forth switching between screens. Nonetheless, 47% of ECRs begin with review of clinical notes, which were also the most common navigation destination. Conclusion Electronic chart review centers around the viewing of clinical notes among MICU clinicians. Convoluted workflows and prolonged searching activities indicate room for system improvement. Using study findings, specific design recommendations to enhance usability for critical care information systems are provided.

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Section: Context Of Other Studiessupporting

confidence: 58%

Section: Background and Significancementioning

confidence: 99%

Health IT Usability Focus Section: Data Use and Navigation Patterns among Medical ICU Clinicians during Electronic Chart Review

et al. 2017

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“…[18][19][20][21] An inefficient EHR can consume the amount of time a clinician spends resulting in cognitive overload, decreased performance levels, clinician stress, and burnout placing patients at risk. 20,[22][23][24][25] Thus, workflow studies that include an analysis of EHR usage are necessary to identify issues and make critical changes to ensure the well-being of patients and clinicians. 26 Our examination of 24/7 EHR usage gave rise to results different from previous time motion studies.…”

Section: Discussionmentioning

confidence: 99%

Impact of Patient Census and Admission Mortality on Pediatric Intensive Care Unit Attending Electronic Health Record Activity: A Preliminary Study

et al. 2020

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Background Physicians may spend a significant amount of time using the electronic health record (EHR), but this is understudied in the pediatric intensive care unit (PICU). The objective of this study is to quantify PICU attending physician EHR usage and determine its association with patient census and mortality scores. Methods During the year 2016, total EHR, chart review, and documentation times of 7 PICU physicians were collected retrospectively utilizing an EHR-embedded time tracking software package. We examined associations between documentation times and patient census and maximum admission mortality scores. Odds ratios (ORs) are reported per 1-unit increase in patient census and mortality scores. Results Overall, total daily EHR usage time (median time [hh:mm] [25th, 75th percentile]) was 2:10 (1:31, 3:08). For all hours (8 a.m.–8 a.m.), no strong association was noted between total EHR time, chart review, and documentation times and patient census, Pediatric Index of Mortality 2 (PIM2), or Pediatric Risk of Mortality 3 (PRISM3) scores. For regular hours (8 a.m.–7 p.m.), no strong association was noted between total EHR, chart review, and documentation times and patient census, PIM2, or PRISM3 scores. When patient census was higher, the odds of EHR after-hour usage (7 p.m.–8 a.m.) was higher (OR 1.262 [1.135, 1.403], p < 0.0001), but there were no increased odds with PIM2 (OR 1.090 [0.956, 1.242], p = 0.20) and PRISM3 (OR 1.010 [0.984, 1.036], p = 0.47) scores. A subset of physicians spent less time performing EHR-related tasks when patient census and admission mortality scores were elevated. Conclusion We performed a novel evaluation of physician EHR workflow in our PICU. Our pediatric critical care physicians spend approximately 2 hours (out of an expected 10-hour shift) each service day using the EHR, but there was no strong or consistent association between EHR usage and patient census or mortality scores. Future larger scale studies are needed to ensure validity of these results.

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“…[31][32][33] Third, forcing the user to decide what to look at next in sequence increases the cognitive burden of assembling the picture. 34,35 This burden is particularly heavy for less-experienced trainees.…”

Section: Assembling a Clinical Picture Under Uncertainty And Time Prementioning

confidence: 99%

“…Finally, the necessity of guessing where to find what you want, and not knowing whether it even exists, adds further cognitive burden and uncertainty. 35 This was described by one participant as clearing a minefield. She needs to find all of the mines, or all of the pieces of information that inform the decision; they could be buried anywhere, and if she misses one, it could lead to tragedy.…”

Section: Assembling a Clinical Picture Under Uncertainty And Time Prementioning

confidence: 99%

User-Centered Clinical Display Design Issues for Inpatient Providers

et al. 2020

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Background Suboptimal information display in electronic health records (EHRs) is a notorious pain point for users. Designing an effective display is difficult, due in part to the complex and varied nature of clinical practice. Objective This article aims to understand the goals, constraints, frustrations, and mental models of inpatient medical providers when accessing EHR data, to better inform the display of clinical information. Methods A multidisciplinary ethnographic study of inpatient medical providers. Results Our participants' primary goal was usually to assemble a clinical picture around a given question, under the constraints of time pressure and incomplete information. To do so, they tend to use a mental model of multiple layers of abstraction when thinking of patients and disease; they prefer immediate pattern recognition strategies for answering clinical questions, with breadth-first or depth-first search strategies used subsequently if needed; and they are sensitive to data relevance, completeness, and reliability when reading a record. Conclusion These results conflict with the ubiquitous display design practice of separating data by type (test results, medications, notes, etc.), a mismatch that is known to encumber efficient mental processing by increasing both navigation burden and memory demands on users. A popular and obvious solution is to select or filter the data to display exactly what is presumed to be relevant to the clinical question, but this solution is both brittle and mistrusted by users. A less brittle approach that is more aligned with our users' mental model could use abstraction to summarize details instead of filtering to hide data. An abstraction-based approach could allow clinicians to more easily assemble a clinical picture, to use immediate pattern recognition strategies, and to adjust the level of displayed detail to their particular needs. It could also help the user notice unanticipated patterns and to fluidly shift attention as understanding evolves.

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A Multisite Survey Study of EMR Review Habits, Information Needs, and Display Preferences among Medical ICU Clinicians Evaluating New Patients

Abstract: Electronic chart review of historical data is an important, prevalent, and potentially time-consuming activity among medical ICU clinicians who would benefit from improved information display systems.

Cited by 13 publications

References 13 publications

Health IT Usability Focus Section: Data Use and Navigation Patterns among Medical ICU Clinicians during Electronic Chart Review

Health IT Usability Focus Section: Data Use and Navigation Patterns among Medical ICU Clinicians during Electronic Chart Review

Impact of Patient Census and Admission Mortality on Pediatric Intensive Care Unit Attending Electronic Health Record Activity: A Preliminary Study

User-Centered Clinical Display Design Issues for Inpatient Providers

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