How can we partner with electronic health record vendors on the complex journey to safer health care?

The Office of the National Coordinator for Health Information Technology released the Safety Assurance Factors for EHR Resilience (SAFER) guides in 2014. Our group developed these guides covering key facets of both electronic health record (EHR) infrastructure (eg, system configuration, contingency planning for downtime, and system-to-system interfaces) and clinical processes (eg, computer-based provider order entry with clinical decision support, test result reporting, patient identification, and clinician-to-clinician communication). The SAFER guides encourage healthy relationships between EHR vendors and users. We conducted a qualitative study over 12 months. We visited 9 health care organizations ranging in size from 1-doctor outpatient clinics to large, multisite, multihospital integrated delivery networks. We interviewed and observed clinicians, IT professionals, and administrators. From the interview transcripts and observation field notes, we identified overarching themes: technical functionality, usability, standards, testing, workflow processes, personnel to support implementation and use, infrastructure, and clinical content. In addition, we identified health care organization-EHR vendor working relationships: marine drill sergeant, mentor, development partner, seller, and parasite. We encourage health care organizations and EHR vendors to develop healthy working relationships to help address the tasks required to design, develop, implement, and maintain EHRs required to achieve safer and higher quality health care.

Lessons learned from implementing service-oriented clinical decision support at four sites: A qualitative study.

OBJECTIVE: To identify challenges, lessons learned and best practices for service-oriented clinical decision support, based on the results of the Clinical Decision Support Consortium, a multi-site study which developed, implemented and evaluated clinical decision support services in a diverse range of electronic health records. METHODS: Ethnographic investigation using the rapid assessment process, a procedure for agile qualitative data collection and analysis, including clinical observation, system demonstrations and analysis and 91 interviews. RESULTS: We identified challenges and lessons learned in eight dimensions: (1) hardware and software computing infrastructure, (2) clinical content, (3) human-computer interface, (4) people, (5) workflow and communication, (6) internal organizational policies, procedures, environment and culture, (7) external rules, regulations, and pressures and (8) system measurement and monitoring. Key challenges included performance issues (particularly related to data retrieval), differences in terminologies used across sites, workflow variability and the need for a legal framework. DISCUSSION: Based on the challenges and lessons learned, we identified eight best practices for developers and implementers of service-oriented clinical decision support: (1) optimize performance, or make asynchronous calls, (2) be liberal in what you accept (particularly for terminology), (3) foster clinical transparency, (4) develop a legal framework, (5) support a flexible front-end, (6) dedicate human resources, (7) support peer-to-peer communication, (8) improve standards. CONCLUSION: The Clinical Decision Support Consortium successfully developed a clinical decision support service and implemented it in four different electronic health records and four diverse clinical sites; however, the process was arduous. The lessons identified by the Consortium may be useful for other developers and implementers of clinical decision support services.

Patient narratives representing patient voices to inform research: a pilot qualitative study.

We are investigating the feasibility and effectiveness of establishing a library of patient narratives to inform patient-centered research in the U.S. Veterans Affairs organization. Using qualitative methods, we conducted a needs assessment of 15 researchers and then interviewed and videotaped 11 veterans with traumatic brain injury or diabetes. We developed a method for displaying the narratives to researchers modeled after a UK initiative called DIPEx and then performed preliminary usability testing. We found that it is not only feasible to provide researchers with patient narratives that could help guide their research, but that similar narratives might be useful to practitioners, health system decision makers, and other patients as well.

A qualitative study of the activities performed by people involved in clinical decision support: recommended practices for success.

OBJECTIVE: To describe the activities performed by people involved in clinical decision support (CDS) at leading sites. MATERIALS AND METHODS: We conducted ethnographic observations at seven diverse sites with a history of excellence in CDS using the Rapid Assessment Process and analyzed the data using a series of card sorts, informed by Linstone's Multiple Perspectives Model. RESULTS: We identified 18 activities and grouped them into four areas. Area 1: Fostering relationships across the organization, with activities (a) training and support, (b) visibility/presence on the floor, (c) liaising between people, (d) administration and leadership, (e) project management, (f) cheerleading/buy-in/sponsorship, (g) preparing for CDS implementation. Area 2: Assembling the system with activities (a) providing technical support, (b) CDS content development, (c) purchasing products from vendors (d) knowledge management, (e) system integration. Area 3: Using CDS to achieve the organization's goals with activities (a) reporting, (b) requirements-gathering/specifications, (c) monitoring CDS, (d) linking CDS to goals, (e) managing data. Area 4: Participation in external policy and standards activities (this area consists of only a single activity). We also identified a set of recommendations associated with these 18 activities. DISCUSSION: All 18 activities we identified were performed at all sites, although the way they were organized into roles differed substantially. We consider these activities critical to the success of a CDS program. CONCLUSIONS: A series of activities are performed by sites strong in CDS, and sites adopting CDS should ensure they incorporate these activities into their efforts.