Doctors documenting: an ethnographic and informatics approach to understanding attending physician documentation in the pediatric emergency department.

OBJECTIVE: The pediatric emergency department is a highly complex and evolving environment. Despite the fact that physicians spend a majority of their time on documentation, little research has examined the role of documentation in provider workflow. The aim of this study is to examine the task of attending physician documentation workflow using a mixed-methods approach including focused ethnography, informatics, and the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework. MATERIALS AND METHODS: In a 2-part study, we conducted a hierarchical task analysis of patient flow, followed by a survey of documenting ED providers. The second phase of the study included focused ethnographic observations of ED attendings which included measuring interruptions, time and motion, documentation locations, and qualitative field notes. This was followed by analysis of documentation data from the electronic medical record system. RESULTS: Overall attending physicians reported low ratings of documentation satisfaction; satisfaction after each shift was associated with busyness and resident completion. Documentation occurred primarily in the provider workrooms, however strategies such as bedside documentation, dictation, and multitasking with residents were observed. Residents interrupted attendings more often but also completed more documentation actions in the electronic medical record. DISCUSSION: Our findings demonstrate that complex work processes such as documentation, cannot be measured with 1 single data point or statistical analysis but rather a combination of data gathered from observations, surveys, comments, and thematic analyses. CONCLUSION: Utilizing a sociotechnical systems framework and a mixed-methods approach, this study provides a holistic picture of documentation workflow. This approach provides a valuable foundation not only for researchers approaching complex healthcare systems but also for hospitals who are considering implementing large health information technology projects.

Safeuristics! Do Heuristic Evaluation Violation Severity Ratings Correlate with Patient Safety Severity Ratings for a Native Electronic Health Record Mobile Application?

OBJECTIVE: Usability of electronic health records (EHRs) remains challenging, and poor EHR design has patient safety implications. Heuristic evaluation detects usability issues that can be classified by severity. The National Institute of Standards and Technology provides a safety scale for EHR usability. Our objectives were to investigate the relationship between heuristic severity ratings and safety scale ratings in an effort to analyze EHR safety. MATERIALS AND METHODS: Heuristic evaluation was conducted on seven common mobile EHR tasks, revealing 58 heuristic violations and 28 unique usability issues. Each usability issue was independently scored for severity by trained hospitalists and a Human Factors researcher and for safety severity by two physician informaticists and two clinical safety professionals. RESULTS: Results demonstrated a positive correlation between heuristic severity and safety severity ratings. Regression analysis demonstrated that 49% of safety risk variability by clinical safety professionals (r = 0.70; n = 28) and 42% of safety risk variability by clinical informatics specialists (r = 0.65; n = 28) was explained by usability severity scoring of problems outlined by heuristic evaluation. Higher severity ratings of the usability issues were associated with increased perceptions of patient safety risk. DISCUSSION: This study demonstrated the use of heuristic evaluation as a technique to quickly identify usability problems in an EHR that could lead to safety issues. Detection of higher severity ratings could help prioritize failures in EHR design that more urgently require design changes. This approach is a cost-effective technique for improving usability while impacting patient safety. CONCLUSION: Results from this study demonstrate the efficacy of the heuristic evaluation technique to identify usability problems that impact safety of the EHR. Also, the use of interdisciplinary teams for evaluation should be considered for severity assessment.

Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project.

Objective: Implementing evidence-based practices requires a multi-faceted approach. Electronic clinical decision support (ECDS) tools may encourage evidence-based practice adoption. However, data regarding the role of mobile ECDS tools in pediatrics is scant. Our objective is to describe the development, distribution, and usage patterns of a smartphone-based ECDS tool within a national practice standardization project. Materials and Methods: We developed a smartphone-based ECDS tool for use in the American Academy of Pediatrics, Value in Inpatient Pediatrics Network project entitled "Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE)." The mobile application (app), PedsGuide, was developed using evidence-based recommendations created by an interdisciplinary panel. App workflow and content were aligned with clinical benchmarks; app interface was adjusted after usability heuristic review. Usage patterns were measured using Google Analytics. Results: Overall, 3805 users across the United States downloaded PedsGuide from December 1, 2016, to July 31, 2017, leading to 14 256 use sessions (average 3.75 sessions per user). Users engaged in 60 442 screen views, including 37 424 (61.8%) screen views that displayed content related to the REVISE clinical practice benchmarks, including hospital admission appropriateness (26.8%), length of hospitalization (14.6%), and diagnostic testing recommendations (17.0%). Median user touch depth was 5 [IQR 5]. Discussion: We observed rapid dissemination and in-depth engagement with PedsGuide, demonstrating feasibility for using smartphone-based ECDS tools within national practice improvement projects. Conclusions: ECDS tools may prove valuable in future national practice standardization initiatives. Work should next focus on developing robust analytics to determine ECDS tools' impact on medical decision making, clinical practice, and health outcomes.

Meta-Analyses of the Effects of Standardized Handoff Protocols on Patient, Provider, and Organizational Outcomes.

OBJECTIVE: The overall purpose was to understand the effects of handoff protocols using meta-analytic approaches. BACKGROUND: Standardized protocols have been required by the Joint Commission, but meta-analytic integration of handoff protocol research has not been conducted. METHOD: The primary outcomes investigated were handoff information passed during transitions of care, patient outcomes, provider outcomes, and organizational outcomes. Sources included Medline, SAGE, Embase, PsycINFO, and PubMed, searched from the earliest date available through March 30th, 2015. Initially 4,556 articles were identified, with 4,520 removed. This process left a final set of 36 articles, all which included pre-/postintervention designs implemented in live clinical/hospital settings. We also conducted a moderation analysis based on the number of items contained in each protocol to understand if the length of a protocol led to systematic changes in effect sizes of the outcome variables. RESULTS: Meta-analyses were conducted on 34,527 pre- and 30,072 postintervention data points. Results indicate positive effects on all four outcomes: handoff information (g = .71, 95% confidence interval [CI] [.63, .79]), patient outcomes (g = .53, 95% CI [.41, .65]), provider outcomes (g = .51, 95% CI [.41, .60]), and organizational outcomes (g = .29, 95% CI [.23, .35]). We found protocols to be effective, but there is significant publication bias and heterogeneity in the literature. Due to publication bias, we further searched the gray literature through greylit.org and found another 347 articles, although none were relevant to this research. Our moderation analysis demonstrates that for handoff information, protocols using 12 or more items led to a significantly higher proportion of information passed compared with protocols using 11 or fewer items. Further, there were numerous negative outcomes found throughout this meta-analysis, with trends demonstrating that protocols can increase the time for handover and the rate of errors of omission. CONCLUSIONS: These results demonstrate that handoff protocols tend to improve results on multiple levels, including handoff information passed and patient, provider, and organizational outcomes. These findings come with the caveat that publication bias exists in the literature on handoffs. Instances where protocols can lead to negative outcomes are also discussed. APPLICATION: Significant effects were found for protocols across provider types, regardless of expertise or area of clinical focus. It also appears that more thorough protocols lead to more information being passed, especially when those protocols consist of 12 or more items. Given these findings, publication bias is an apparent feature of this literature base. Recommendations to reduce the apparent publication bias in the field include changing the way articles are screened and published.

Directly Comparing Handoff Protocols for Pediatric Hospitalists.

BACKGROUND AND OBJECTIVES: Handoff protocols are often developed by brainstorming and consensus, and few are directly compared. We hypothesized that a handoff protocol (Flex 11) developed using a rigorous methodology would be more favorable in terms of clinicians' attitudes, behaviors, cognitions, or time-on-task when performing handoffs compared with a prevalent protocol (Situation Background Assessment Recommendation [SBAR]). METHODS: Using a between-groups, randomized control trial design (Flex 11 versus SBAR) during a pilot study in a simulated environment, 20 clinicians (13 attending physicians and 7 residents) received 3 patient handoffs from a standardized physician, managed the patients, and handed off the patients to the same standardized physician. Participants completed surveys assessing their attitudes and cognitions, and behaviors and handoff duration were assessed through observations. RESULTS: All data were analyzed using independent samples t tests. For attitudes, "ease of use" ratings were lower for SBAR participants than Flex 11 participants (P < .01), and "being helpful" ratings were lower for SBAR participants than Flex 11 participants (P = .02). For behaviors, results indicate no significant difference in the information acquired between the SBAR and Flex 11 protocols. However, SBAR participants gave significantly less information than Flex 11 participants (P < .01). For cognitions, SBAR and Flex 11 participants reported similar workload except for frustration. For handoff duration, there were no significant differences between the protocols (P = .36). CONCLUSIONS: The results suggest that Flex 11 is an efficient, beneficial tool in a simulated environment with pediatric clinicians. Future studies should evaluate this protocol in the inpatient setting.

The effect of defaults in an electronic health record on laboratory test ordering practices for pediatric patients.

OBJECTIVE: Defaults have been shown to impact decision making in a variety of domains. However, no research has applied defaults to medical care decisions utilizing an Electronic Health Record (EHR). This research was designed to examine how providers' inpatient laboratory ordering practices were influenced by default selections in EHR order sets. METHOD: Providers were asked to complete inpatient admission orders for six fictitious pediatric patients using three EHR interface designs: opt-in (no laboratory tests preselected), opt-out (all laboratory tests preselected), or recommended (only laboratory tests recommended by pediatric experts preselected). EHR design was manipulated within subjects. Seventy-two providers from a Midwestern pediatric hospital reviewed the six cases and completed admission orders for all cases, entering two cases with each EHR design. Order of the cases and EHR designs were counterbalanced across participants. RESULTS: When all laboratory tests were preselected, providers ordered significantly more tests and increased the cost of admission by more than $70 when compared with the opt-in, p < .01, and recommended EHR designs, p < .01. Furthermore, providers ordered more tests recommended by the pediatric experts when using the recommended design than when using the opt-in design, p = .03, although the total number of tests ordered did not differ significantly, p = .97. CONCLUSIONS: This study demonstrated that default selections in an EHR can significantly influence providers' laboratory test ordering practices and that hospital systems could benefit from adding expert-recommended defaults to EHR order sets.

Essentials of laboratory medicine for the nephrology clinician.

The purpose of this review is to compile and bring to the attention of the pediatric nephrology community various aspects of laboratory medicine pertinent to nephrology. The review addresses different aspects in laboratory medicine that should be taken into account during interpretation of a test result, such as methodological and analytical issues, statistical considerations and the biological interpretation of a test result in the context of the clinical setting. An understanding of the considerations and limitations in laboratory medicine will be helpful to the pediatric nephrologist when ordering and interpreting biochemical tests.