Improving the EMR Experience

Approaches to Improving Decision Making, Evidence that Shows These Work, and How

to Make ChangesSeth Scott

Objectives

• Discuss basics of Clinical Decision Support • Show different ways to improve the EMR

– Templates– Order sets– Warnings

• Show how these types of changes might be done• Show evidence these changes lead to multiple types of

improvements• Stimulate discussion about what changes the

hospitalist group might want to make in power chart

Why this is important?

• Under current system– All laboratory data is obtained from computer– All documentation is done in cerner– All order entry is done in the computer

• There is some evidence better user interface leads to– More efficient resource use– Saves time for the provider– “better” documentation– Improves patient safety

GENERAL INFORMATION REGARDING DESIGN OF CDS INTERVENTIONS

Elements to present in a Clinical Decision Support Intervention

• A clear statement of reason for intervention• Supporting data for the intervention• Information to explain options• Easy access to an appropriate change• Way to document appropriate disagreement

with the intervention• A method to give feedback to intervention

owners

Osherhoff Et Al

Improving usability with heuristic evaluation

• A heuristic evaluation is a common way of evaluating a computer system to identify problems with user interface – Several people use a mock up and try to identify

problems– Some authors have developed a framework to

classify usability errors (zhang et Al)• Called Nielsen–Shneiderman Heuristics• Many of these may apply to changes that we might

make

Applicable Nielsen–Shneiderman Heuristics

• Consistency– The user shouldn’t

wonder if different words/actions mean the same thing

• Minimalist – Extraneous information

slows the user and is a distraction

• Minimize Memory Load– The user shouldn’t have

to have memorized lots of information to carry out tasks. Make use of default values

• Feedback– Users should get prompt

feedback regarding their actions

More heuristics

• Flexibility– User should be able to

customize and have shortcuts for frequent actions.

• Good error messages– Inform user of nature of

error so they can learn from them, specific about what the error is.

• Closure – User should clearly know

a task is done

• Undo– Users should be able to

undo their actions easily

• Prevent Error– Design system so as to

make it hard/impossible to commit errors

DOCUMENTATION FORMS

Description

• Templated forms/notes– May be specific for particular

diagnosis – Leave blanks/data fields for

desired information– Progress notes

• Prevent omission errors by displaying relevant information to provider while note being written

• Prevent commission errors by capturing critical data i.e allergies

• Might include calculated values

– Consult forms• Ensure appropriate person gets

information• Allows receiver of consult to select

what info they want beforehand

• Current Examples– =imhm template– Adhoc consult forms

• Consideration to improve frequency of use– A systematic way of naming

these forms is needed to ensure providers will use

– Thereby Will make analysis of the form more useful

• Problems– May clutter EMR with

unecessary/unreviewed information

Evidence for Use

• Davis Et al– Using an EMR to Improve

Asthma Severity Documentation and Treatment Among Family Medicine Residents

– Looked at changes in Asthma documentation with use of a template for documentation

– Included an educational component to inform providers of the template and its components

• Results– Showed use of a

template in Asthma documentation improved• Documentation of Asthma

Severity• Increased appropriate use

of Inhaled corticosteroids

More evidence for use of templates to improve documentation

• Yates, K whose article “Using a template in fracture clinic leads to a sustained improvement in clinical notes”

• Looked at improvement in documentation following implementation of education and template– Looked at inclusion of certain

values in notes– Initial improvement likely

related to education component

• These included – Neurovascularly intact– Name/date– Range of motion– Handedness– Pain

• Compared to other clinic at same site the site using template had– Increased % of patients

who had Neurovascular intact, ROM, Handedness, Pain documented 3 yrs later.

Results

ORDER SETS

Description

• List of vetted orders that can be clicked on

• Default doses, duration, and frequency, included

• Advantages:– Ensures adherence to

current evidence by making the right thing easy

– Frequently faster than -“a-la-carte” order entry

• Disadvantages– Not used if not

listed/organized in a coherent fashion

– “Cookbook” medicine

• Current Examples– Adult Medicine Admit

Orders– Adult Work Up TB

• In power chart currently includes care sets folders and power plans

Evidence for Use• Khajouei et Al

– Looked at simulated use of order sets

– For simulated patient with APML– Compared orderset to paper, and

ala carte orders.– Used Medicator software– In academic medical center in

Netherlands– ½ of participants did order set 1st

and ½ did ala carte 1st. – Recorded number of clicks and

keystrokes compared this to optimum number of clicks/kestrokes

– Evaluated usability errors with Nielsen–Shneiderman Heuristics and classified them

• Findings– Excess clicks/keystrokes

significantly reduced with order sets• 16-72 vs 92-416

– Major/catastrophic problems with usability less in the order set group than the ala-carte group

Key Data from Khajouei et Al

Another Example this time with clinical data

• Mayorga and Rockey looked at use of an order set for UGIB in cirrhosis

• 123 patients • Parkland Memorial Hospital

Dallas• Prospective Observational trial• Looked at compliance and

time to use of the following before and after starting an orderset. – Antibiotics– octreotide – Endoscopy

• Hospitalized/ICU patients• Admitted with diagnosis of

UGIB (defined as witnessed hematemesis/ coffee grounds) and cirrhosis

• Order set use at physician discretion

• Found that with order set use improved compliance with antibiotics faster administration of both antibiotics and octreotide

Results

ALERTS/WARNINGS

Description

• Pop-up warning following a specific action

• Allow user to change plan based on information in the system

• Current Examples– Allergy Alerts – Drug interaction alerts

• Advantages– Can be used to prevent

catastrophic errors, ensure cost effective ordering

• Disadvantages– Irritating when falsely

popping up– Frequent use leads to alert

fatigue causing providers to ignore critical warnings

– Efficacy dependent on what percent of time alert leads to change in plan

Evidence of Utility

• Levick Et al.– Observational study– Took place at Lehigh

Valley Heath Network– Looked at effects of

adding an alert on ordering patterns

– If a BNP was in the system from that visit the provider was given the alert to the right

Results of Levick Et Al• Reduced number of

orders for BNP by 0.6 tests per inpatient admit

• Led to overall ~20% reduction in testing

• Saved $92,000 in direct costs

One way changes have been done

Pneumonia care set

Where to start changes

• https://hospitals.health.unm.edu/intranet/synerge3/req_forms.shtml

Summary and Things to Bear in Mind

• Small studies looking at changes in computer orders have shown improvements in provider efficiency, resource utilization, and surrogate secondary outcomes

• Minimal hard outcomes data currently available on computer interventions (opportunity?)

• Most studies have had some educational component• Power plans can be made without the initiate feature• Power plans can be discontinued as a group• Power plans will include improvements from cerner

that care sets or folders will not

DISCUSSION AND QUESTIONS

Bibliography• Mayorga C, and Rockey D. Clinical Utility of a Standardized Electronic Order Set for the

Management of Acute Upper Gastrointestinal Hemorrhage in Patients with Cirrhosis. Clinical Gastroenterology and Hepatology. Apr 29 2013. doi:pii: S1542-3565(13)00581-8

• Levick D, Stern G, Meyerhoefer O, Levick A Pucklavage D Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention. BMC Med Inform Decis Mak. 2013 Apr 8;13:43.

• Yates, K. Using a template in fracture clinic leads to a sustained improvement in clinical notes. Injury 2009 Feb;40(2):177-80.

• Khajouei R, Peek N, Wierenga PC, Kersten MJ, and Jaspers MW. Effect of predefined order sets and usability problems on efficiency of computerized medication ordering. Int J Med Inform. 2010 Oct;79(10):690-8. doi: 10.1016/j.ijmedinf.2010.08.001.

• Zhang J, Johnson TR, Patel VL, Paige DL, Kubose T. Using usability heuristics to evaluate patient safety of medical devices. J Biomed Inform. 2003 Feb-Apr;36(1-2):23-30.

• Levick, D, Saldana,L, Velasco F, Sittig, D, Rogers K, Jenders, R. Improving Outcomes with Clinical Decision Support:an Implementer's Guide, Second Edition HIMSS; 2nd edition (January 1, 2012)

• Special thanks to Aaron Jacobs