To support a pragmatic, electronic health record (EHR)-based randomized controlled trial, we applied user-centered design (UCD) principles, evidence-based risk communication strategies, and ...interoperable software architecture to design, test, and deploy a prognostic tool for children in emergency departments (EDs) with pneumonia.
Risk for severe in-hospital outcomes was estimated using a validated ordinal logistic regression model to classify pneumonia severity. To render the results usable for ED clinicians, we created an integrated SMART on FHIR web application built for interoperable use in two pediatric EDs using different EHR vendors: Epic and Cerner. We followed a UCD framework, including problem analysis and user research, conceptual design and early prototyping, user interface development, formative evaluation, and post-deployment summative evaluation.
Problem analysis and user research from 39 clinicians and nurses revealed user preferences for risk aversion, accessibility, and timing of risk communication. Early prototyping and iterative design incorporated evidence-based design principles, including numeracy, risk framing, and best-practice visualization techniques. After rigorous unit and end-to-end testing, the application was successfully deployed in both EDs, which facilitatd enrollment, randomization, model visualization, data capture, and reporting for trial purposes.
The successful implementation of a custom application for pneumonia prognosis and clinical trial support in two health systems on different EHRs demonstrates the importance of UCD, adherence to modern clinical data standards, and rigorous testing. Key lessons included the need for understanding users' real-world needs, regular knowledge management, application maintenance, and the recognition that FHIR applications require careful configuration for interoperability.
Cognitive aids (CA), including emergency manuals and checklists, are tools designed to assist users in prioritizing and performing complex tasks during time sensitive, high stress situations ...(Marshall in Anesth Analgesia 117(5):1162–1171,
2013
; Marshall and Mehra in Anaesthesia 69(7):669–677,
2014
). The society for pediatric anesthesia (SPA) has developed a series of emergency checklists tailored for use by pediatric perioperative teams that cover a wide range of intraoperative critical events (Shaffner et al. in Anesth Analgesia 117(4):960–979,
2013
). In this study, we evaluated user preferences for a CA (SPA checklist) using two different presentation formats, paper and electronic, during management of simulated critical events. Anesthesia trainees managed the simulated critical events under one of three randomized conditions: (1) memory alone, (2) with a paper version of the CA, (3) with an electronic version of the CA. Following participation in the simulated critical events, participants were asked to complete a survey regarding their experience using the different versions of the CA. The percentage of favorable responses for each format of the CA was compared using a mixed effects proportional odds model. There were 143 simulated events managed by 89 anesthesia trainees. Approximately one out of three trainees (electronic 29 %, paper 30 %) assigned to use the CA chose not to use it and completed the scenario from memory alone. The survey was completed by 68 % of participants, 58 % of trainees preferred the paper version and 35 % preferred the electronic version. All survey responses that reached statistical significance favored the paper version. In this study, anesthesia trainees had a favorable opinion of the content and perceived clinical relevance of both versions of the CA. In both quantitative and qualitative analysis, the paper version of the CA was preferred over the electronic version by participants. Despite overall favorable responses to the CA, a sizeable number of participants chose not to use either version the CA during the crisis.
•Effective clinical decision support (CDS) requires proper 'fit' within clinical work.•CDS should identify and target communication hubs (resident physicians).•CDS should be available in clinical ...work distributed across people, location, and time.•CDS should be integrated within early steps of clinical assessment and planning.•CDS should be available in electronic & hardcopy format.
In healthcare, the routine use of evidence-based specialty care management plans is mixed. Targeted computerized clinical decision support (CCDS) interventions can improve physician adherence, but adoption depends on CCDS’ ‘fit’ within clinical work. We analyzed clinical work in outpatient and inpatient settings as a basis for developing guidelines for optimizing CCDS design.
The contextual design approach guided data collection, collation and analysis. Forty (40) consenting physicians were observed and interviewed in general internal medicine inpatient units and gastroenterology (GI) outpatient clinics at two academic medical centers. Data were collated using interpretive debriefing, and consolidated using thematic analysis and three work modeling approaches (communication flow, sequence and artifact models).
Twenty-six consenting physicians were observed at Site A and 14 at Site B. Observations included attending (33%) and resident physicians. During research team debriefings, 220 of 341 unique topics were categorized into 5 CCDS-relevant themes. Resident physicians relied on patient assessment & planning processes to support their roles as communication and coordination hubs within the medical team. Artifact analysis further elucidated the evolution of assessment and planning over work shifts.
The usefulness of CCDS tools may be enhanced in clinical care if the design: 1) accounts for clinical work that is distributed across people, space, and time; 2) targets communication and coordination hubs (specific roles) that can amplify the usefulness of CCDS interventions; 3) integrates CCDS with early clinical assessment & planning processes; and 4) provides CCDS in both electronic & hardcopy formats. These requirements provide a research agenda for future research in clinician-CCDS integration.
User-Centered Design Means Better Patient Care Tippey, Kathryn G; Weinger, Matthew B
Biomedical instrumentation & technology,
2017 May/Jun, 2017-05-00, 20170501, Volume:
51, Issue:
3
Journal Article
Peer reviewed
To Err is Human and Crossing the Quality Chasm highlighted the need for healthcare to focus on patient safety, launching several decades of effort and modest success in reducing unnecessary patient ...harm. In parallel, emphasis on patient-centered care, defined as "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions," has increased. In this article, the authors examine how these two "movements" can align through the application of user-centered design (UCD) processes to develop patient-facing medical technologies that are safer, more usable, and more patient centered. Effective application of UCD principles yields patient-facing technologies that are more likely to lower treatment burden, increase patient engagement, and allow patients to become more self-sufficient. However, failure to apply UCD principles, which means not taking into account users' needs and their expectations of how the device functions, especially when used at home, has the potential to result in harmful outcomes.
The Composition of Intern Work While on Call Fletcher, Kathlyn E.; Visotcky, Alexis M.; Slagle, Jason M. ...
Journal of general internal medicine : JGIM,
11/2012, Volume:
27, Issue:
11
Journal Article
Peer reviewed
Open access
ABSTRACT
BACKGROUND
The work of house staff is being increasingly scrutinized as duty hours continue to be restricted.
OBJECTIVE
To describe the distribution of work performed by internal medicine ...interns while on call.
DESIGN
Prospective time motion study on general internal medicine wards at a VA hospital affiliated with a tertiary care medical center and internal medicine residency program.
PARTICIPANTS
Internal medicine interns.
MAIN MEASURES
Trained observers followed interns during a “call” day. The observers continuously recorded the tasks performed by interns, using customized task analysis software. We measured the amount of time spent on each task. We calculated means and standard deviations for the amount of time spent on six categories of tasks: clinical computer work (e.g., writing orders and notes), non-patient communication, direct patient care (work done at the bedside), downtime, transit and teaching/learning. We also calculated means and standard deviations for time spent on specific tasks within each category. We compared the amount of time spent on the top three categories using analysis of variance.
KEY RESULTS
The largest proportion of intern time was spent in clinical computer work (40 %). Thirty percent of time was spent on non-patient communication. Only 12 % of intern time was spent at the bedside. Downtime activities, transit and teaching/learning accounted for 11 %, 5 % and 2 % of intern time, respectively.
CONCLUSION
Our results suggest that during on call periods, relatively small amounts of time are spent on direct patient care and teaching/learning activities. As intern duty hours continue to decrease, attention should be directed towards preserving time with patients and increasing time in education.
Management of critical events requires teams to employ nontechnical skills (NTS), such as teamwork, communication, decision making, and vigilance. We sought to estimate the reliability and provide ...evidence for the validity of the ratings gathered using a new tool for assessing the NTS of anesthesia providers, the behaviorally anchored rating scale (BARS), and compare its scores with those of an established NTS tool, the Anaesthetists' Nontechnical Skills (ANTS) scale.
Six previously trained raters (4 novices and 2 experts) reviewed and scored 18 recorded simulated pediatric crisis management scenarios using a modified ANTS and a BARS tool. Pearson correlation coefficients were calculated separately for the novice and expert raters, by scenario, and overall.
The intrarater reliability of the ANTS total score was 0.73 (expert, 0.57; novice, 0.84); for the BARS tool, it was 0.80 (expert, 0.79; novice, 0.81). The average interrater reliability of BARS scores (0.58) was better than ANTS scores (0.37), and the interrater reliabilities of scores from novices (0.69 BARS and 0.52 ANTS) were better than those obtained from experts (0.47 BARS and 0.21 ANTS) for both scoring instruments. The Pearson correlation between the ANTS and BARS total scores was 0.74.
Overall, reliability estimates were better for the BARS scores than the ANTS scores. For both measures, the intrarater and interrater reliability was better for novices compared with domain experts, suggesting that properly trained novices can reliably assess the NTS of anesthesia providers managing a simulated critical event. There was substantial correlation between the 2 scoring instruments, suggesting that the tools measured similar constructs. The BARS tool can be an alternative to the ANTS scale for the formative assessment of NTS of anesthesia providers.
The ultimate goal of physician education is the application of knowledge and skills to patient care. The Maintenance of Certification (MOC) for Anesthesiologists program incorporates mannequin‐based ...simulation to help realize this goal. Results from the first 2 years of experience suggest that 583 physician participants transferred knowledge and skills from their simulated experiences into real‐world practice. Participants consistently found the experience educationally valuable and clinically relevant, and reported that it led to changes in practice. This first experience with mannequin‐based simulation for MOC indicates that physicians accept this teaching modality, many with enthusiasm. Simulation education addresses many of the identified intentions of current continuing medical education (CME) and can help educators realize goals for educating physician‐learners.
The Preemptive Pharmacogenetic-guided Metoprolol Management for Atrial Fibrillation in Cardiac Surgery (PREEMPTIVE) pilot trial aims to use existing institutional resources to develop a process for ...integrating CYP2D6 pharmacogenetic test results into the patient electronic health record, to develop an evidence-based clinical decision support tool to facilitate CYP2D6 genotype-guided metoprolol administration in the cardiac surgery setting, and to determine the impact of implementing this CYP2D6 genotype-guided integrated approach on the incidence of postoperative atrial fibrillation (AF), provider, and cost outcomes.
One-arm Bayesian adaptive design clinical trial.
Single center, university hospital.
The authors will screen (including CYP2D6 genotype) up to 600 (264 ± 144 expected under the adaptive design) cardiac surgery patients, and enroll up to 200 (88 ± 48 expected) poor, intermediate, and ultrarapid CYP2D6 metabolizers over a period of 2 years at a tertiary academic center.
All consented and enrolled patients will receive the intervention of CYP2D6 genotype-guided metoprolol management based on CYP2D6 phenotype classified as a poor, intermediate, extensive (normal), or ultrarapid metabolizer.
The primary outcome will be the incidence of postoperative AF. Secondary outcomes relating to rates of CYP2D6 genotype-guided prescription changes, costs, lengths of stay, and implementation metrics also will be investigated.
The PREEMPTIVE pilot study is the first perioperative pilot trial to provide essential information for the design of a future, large-scale trial comparing CYP2D6 genotype-guided metoprolol management with a nontailored strategy in terms of managing AF. In addition, secondary outcomes regarding implementation, clinical benefit, safety, and cost-effectiveness in patients undergoing cardiac surgery will be examined.
OBJECTIVEThe aim of the study was to determine the incidence, type, severity, preventability, and contributing factors of nonroutine events (NREs)—events perceived by care providers or skilled ...observers as a deviations from optimal care based on the clinical situation—in the perioperative (i.e., preoperative, operative, and postoperative) care of surgical neonates in the neonatal intensive care unit and operating room.
METHODSA prospective observational study of noncardiac surgical neonates, who received preoperative and postoperative neonatal intensive care unit care, was conducted at an urban academic childrenʼs hospital between November 1, 2016, and March 31, 2018. One hundred twenty-nine surgical cases in 109 neonates were observed. The incidence and description of NREs were collected via structured researcher-administered survey tool of involved clinicians. Primary measurements included cliniciansʼ ratings of NRE severity and contributory factors and trained research assistantsʼ ratings of preventability.
RESULTSOne or more NREs were reported in 101 (78%) of 129 observed cases for 247 total NREs. Clinicians reported 2 (2) (median, interquartile range) NREs per NRE case with a maximum severity of 3 (1) (possible range = 1–5). Trained research assistants rated 47% of NREs as preventable and 11% as severe and preventable. The relative risks for National Surgical Quality Improvement Program – pediatric major morbidity and 30-day mortality were 1.17 (95% confidence interval = 0.92–1.48) and 1.04 (95% confidence interval = 1.00–1.08) in NRE cases versus non-NRE cases.
CONCLUSIONSThe incidence of NREs in neonatal perioperative care at an academic childrenʼs hospital was high and of variable severity with a myriad of contributory factors.
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