Association of the Usability of Electronic Health Records With Cognitive Workload and Performance Levels Among Physicians.

Readers have little trouble finding articles about electronic health records. Unfortunately, most users have little good to say about their EHR except that is has a good memory and never forgets. The trouble lies in data entry and its interference with clinical workflow.


This JAMA article by Lukasz M. Mazur, PhD^1,2,3; Prithima R. Mosaly, PhD^1,2,3 Carlton Moore, MD^1,2,4 Carleton Moore M.D.; et al .  asks and elaborates on several key questions.

Key Points

Question  Is enhanced usability of an electronic health record system associated with physician cognitive workload and performance?

Findings  In this quality improvement study, physicians allocated to perform tasks in an electronic health record system with enhancement demonstrated statistically significantly lower cognitive workload; those who used a system with enhanced longitudinal tracking appropriately managed statistically significantly more abnormal test results compared with physicians allocated to use the baseline electronic health record.

Meaning  Usability improvements in electronic health records appear to be associated with improved cognitive workload and performance levels among clinicians; this finding suggests that next-generation systems should strip away non–value-added interactions.

This deficit has been recognized by those developers who design EHR.  Good news! It has been a long time coming! 

Importance  Current electronic health record (EHR) user interfaces are suboptimally designed and may be associated with excess cognitive workload and poor performance.

Objective  To assess the association between the usability of an EHR system for the management of abnormal test results and physicians’ cognitive workload and performance levels. Relatively basic usability enhancements to the EHR system appear to be associated with better physician cognitive workload and performance; this finding suggests that next-generation systems should strip away non–value-added EHR interactions, which may help physicians eliminate the need to develop their own suboptimal workflows.

Study setting:

This quality improvement study was conducted in a simulated EHR environment. From April 1, 2016, to December 23, 2016, residents and fellows from a large academic institution were enrolled and allocated to use either a baseline EHR (n = 20) or an enhanced EHR (n = 18). Data analyses were conducted from January 9, 2017, to March 30, 2018. The study was done using GCP and sound scientific guidelines for constructing a reliable and credible study.

The simulated scenarios were iteratively developed and tested by an experienced physician and human factors engineer (C.M. and L.M.) in collaboration with an Epic software developer from the participating institution. The process included functionality and usability testing and took approximately 12 weeks to complete. The experimental design was based on previous findings that attending physicians use the EHR to manage approximately 57 test results per day over multiple interactions.^22,23 

At the conclusion of the study, an evaluation of the changes was performed based upon Perceived Workload, Physiological Workload, and Performance.  In addition to these factors, Secondary Outcome and Measures were evaluated.

Fatigue can affect perceived and physiological workload and performance and thus can confound study results.^41-43 Because of the possible confounding association of fatigue, participants were asked to evaluate their own state of fatigue immediately before each simulated session using the fatigue portion of the Crew Status Survey.⁴⁴ The fatigue assessment scale included these levels: 1 (fully alert, wide awake, or extremely peppy), 2 (very lively, or responsive but not at peak), 3 (okay, or somewhat fresh), 4 (a little tired, or less than fresh), 5 (moderately tired, or let down), 6 (extremely tired, or very difficult to concentrate), and 7 (completely exhausted, unable to function effectively, or ready to drop). The Crew Status Survey has been tested in real and simulated environments and has been found to be both reliable and able to discriminate between fatigue levels.^44,45

Relatively basic usability enhancements to EHR systems appear to be associated with improving physician management of abnormal test results while reducing cognitive workload. The findings from this study support the proactive evaluation of other similar usability enhancements that can be applied to other interfaces within EHRs.

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Help may be on the way.

The electronic health record evaluated was EPIC. Epic is the largest provider (if not one of the top three) for a large group and/or hospitals.

Association of the Usability of Electronic Health Records With Cognitive Workload and Performance Levels Among Physicians. | Electronic Health Records | JAMA Network Open | JAMA Network: Question  Is enhanced usability of an electronic health record system associated with physician cognitive workload and performance?

Scientists Print First 3D Heart Using Patient's Biological Materials

In a major medical breakthrough, Tel Aviv University researchers have "printed" the world's first 3D vascularised engineered heart using a patient's own cells and biological materials. Their findings were published on April 15 in a study in Advanced Science.

Until now, scientists in regenerative medicine -- a field positioned at the crossroads of biology and technology -- have been successful in printing only simple tissues without blood vessels.

"This is the first time anyone anywhere has successfully engineered and printed an entire heart replete with cells, blood vessels, ventricles, and chambers," says Prof. Tal Dvir of TAU's School of Molecular Cell Biology and Biotechnology, Department of Materials Science and Engineering, Center for Nanoscience and Nanotechnology and Sagol Center for Regenerative Biotechnology, who led the research for the study.

Heart disease is the leading cause of death among both men and women in the United States. Heart transplantation is currently the only treatment available to patients with end-stage heart failure. Given the dire shortage of heart donors, the need to develop new approaches to regenerate the diseased heart is urgent.

"This heart is made from human cells and patient-specific biological materials. In our process these materials serve as the bio links, substances made of sugars and proteins that can be used for 3D printing of complex tissue models," Prof. Dvir says. "People have managed to 3D-print the structure of a heart in the past, but not with cells or with blood vessels. Our results demonstrate the potential of our approach for engineering personalized tissue and organ replacement in the future."

For the research, a biopsy of fatty tissue was taken from patients. The cellular and a-cellular materials of the tissue were then separated. While the cells were reprogrammed to become pluripotent stem cells, the extracellular matrix (ECM), a three-dimensional network of extracellular macromolecules such as collagen and glycoproteins, were processed into a personalized hydrogel that served as the printing "ink."

After being mixed with the hydrogel, the cells were efficiently differentiated to cardiac or endothelial cells to create patient-specific, immune-compatible cardiac patches with blood vessels and, subsequently, an entire heart.

According to Prof. Dvir, the use of "native" patient-specific materials is crucial to successfully engineering tissues and organs.

"The biocompatibility of engineered materials is crucial to eliminating the risk of implant rejection, which jeopardizes the success of such treatments," Prof. Dvir says. "Ideally, the biomaterial should possess the same biochemical, mechanical and topographical properties of the patient's own tissues. Here, we can report a simple approach to 3D-printed thick, vascularized and perfusable cardiac tissues that completely match the immunological, cellular, biochemical and anatomical properties of the patient."

The researchers are now planning on culturing the printed hearts in the lab and "teaching them to behave" like hearts, Prof. Dvir says. They then plan to transplant the 3D-printed heart in animal models.

Journal Reference:

Nadav Noor, Assaf Shapira, Reuven Edri, Idan Gal, Lior Wertheim, Tal Dvir. 3D Printing of Personalized Thick and Perfusable Cardiac Patches and Hearts. Advanced Science, 2019; 1900344 DOI: 10.1002/advs.201900344

Scientists print first 3D heart using patient's biological materials: Engineered heart completely matches the immunological, cellular, biochemical and anatomical properties of the patient -- ScienceDaily: Scientists print first 3D heart using patient's biological materials

Request A Virtual Doctor Visit Directly from Google, Bing, Yelp

Where do you want to go? Despite and because of the proliferation of online web sites and the decline of printed directories do you wonder where the best place(s) is to find a physician?

Request A Virtual Doctor Visit Directly from Google, Bing, Yelp

Google, Yelp and Bing are sources, however, the results overwhelm most searchers because they are not specific and include unrelated search results including promoted sites.

VSee, a San Jose-based telemedicine company and Doctor.com, a web-wide listings management, reputation, and patient communications platform — are partnering to create a seamless online patient journey from Google, Bing, Yelp search for a virtual visit. Doctor.com’s platform currently serves more than 200K providers and leverages the only partner network in the industry of 50+ integrations, including Google, Bing, Yelp, Healthgrades, Vitals, YP, and other major consumer health destinations.

The VSee and Doctor.com vision are unlike the failed Google Helpouts for Health which tried to match those Googling health symptoms with a live provider. Helpouts also required providers and patients to have Google+ accounts. Instead, the VSee and Doctor.com partnership focus on enhancing provider profiles and using what they already know about how patients choose a physician online. From search to a video telehealth visit,  the integration will enable providers to expand their practice reach.

Dr. Milton Chen, VSee CEO, says, “Currently it’s too much work to go from searching for a doctor to consulting with a doctor. VSee envisions a seamless experience where we can go directly from a Google or Bing search to live chatting with a doctor’s front desk. From the search or live chat we can then book a telehealth appointment or do a walk-in video visit. VSee is excited about our partnership with Doctor.com to revolutionize and streamline the process of finding and seeing a doctor online.

At this time it seems an overkill because they only represent 200,000 providers, less than one-quarter of providers.  Situations change rapidly, including provider groups and health plans.

Millennial patients feast on this type of platform, using a one click-stop to shop application.

Impact of Partnership

According to a Salesforce report, 60% of millennials support the use of telehealth visits as a replacement for in-person visits. Doctor.com’s 2018 CX Trends in Healthcare report found that nearly 70% of consumers will choose one provider over another because of a strong online presence and an Accenture report found that 84% of patients use online reviews to choose a doctor. As millennials and digital natives become the dominant consumer group, telehealth will continue to grow in demand, and an online presence will become increasingly important for provider practices.




















Request A Virtual Doctor Visit Directly from Google, Bing, Yelp: VSee and Doctor.com are partnering to create a seamless online patient journey from Google, Bing, Yelp search to virtual visit.

Electronic health records lack tools to improve clinical care

Author
Lloyd B. Minor, M.D., is professor of otolaryngology — head and neck surgery and dean of the Stanford University School of Medicine.

Early in my career as an  eye surgeon, an ear nose and throat surgeon told me about two different patients who came to him with the same set of bizarre symptoms. Certain noises made their eyes move involuntarily, and objects they were looking at appeared to move around in patterns. After months of careful investigation, these patients led me to discover a rare disorder called superior semicircular canal dehiscence and to develop a corrective surgery for it.

Today, anyone with Internet access can search the symptoms of superior semicircular canal dehiscence and get multiple hits for diagnosis and information about treatment. Yet most doctors who use electronic health records are years away from this kind of capability. There is no search engine to support our clinical decision making. That essential part of health care remains a practice of informed guesswork, and we are often unable to access information that could improve decisions in the moment of care and make health care far safer and more effective and efficient than it is today.

A recent article published jointly by Kaiser Health News and Fortune and my own personal experience are stark reminders for me that electronic health records have not yet lived up to their true potential. In addition to highlighting their inability to share information across proprietary platforms, as well as the fact that physicians report spending more time than ever on data entry rather than interacting with patients, the in-depth investigation uncovered thousands of incidents in which errors caused by faulty electronic health records harmed patients.

As a physician, I find this deeply worrisome. A full decade after passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act — legislation that originally set aside $27 billion to incentivize physicians and hospitals to adopt EHRs — we still have a long way to go. I see little if no progress in remediation of this serious deficiency.  

I see this failing to progress as the total lack of incentive for existing vendors to re-write their software. The federal government has overemphasized MACRA, MIPS as measures of meaningful use, a bureaucratic means of totally ignoring this situation. Their measures are a poor measure of quality and outcomes. They have mistakenly or on purpose tied reimbursement to these measures.  If anything it has reduced the quality of care by overloading physicians and professionals with clerical duties, mindless clicking, opening and closing screens, in a search for information and entering new information. This is not a new problem. For the past ten years physicians, and their organizations have been vocal about the loss of patient facetime, longer work days, and physician burnout.  Many doctors have retired well before the end of a useful career life, choosing to do non-clinical work. This is adding to the physician shortage. It is an easy calculation.

In 2018, a Stanford Medicine/Harris Poll found that nearly half of U.S. primary care physicians said that electronic health records actually detract from their effectiveness as clinicians, and 44% said they believed that the primary value of these systems is data storage. Far from being a transformative health care tool to support clinical decision-making, a large portion of physicians feel they have traded physical filing cabinets for digital ones.

Electronic health records still have the potential to make health care more predictive, preventive, and precise — but only if we can achieve sustained collaboration among health care providers, technology companies, and health insurers to address their shortcomings. One step in that direction took place on Stanford’s campus last June, where we convened leaders in patient care, technology, design thinking, and policy to discuss a path forward for electronic health records. In principle, the group agreed on three points:

First, electronic health record systems must become interoperable, meaning that a doctor using an Epic system should be easily able to send patient information to a doctor using a Cerner system, or one from athenahealth. Fewer than one in three hospitals can functionally share and use patient information received from another provider. This is the most important challenge, one that will require a combination of technical and operational solutions. The health care industry, including insurers, must agree to common technical standards to effortlessly exchange data, and providers must enforce these standards through shared contracting requirements with technology vendors.

Second, electronic health records must be redesigned to better respond to physicians’ needs. Doctors complain about the dozens of clicks it can take to order a simple test or submit a prescription. Physicians and developers must work together to build new systems or update existing ones so they better reflect the rhythms of clinical care. This will take time to build and training to implement, but such investments are worthwhile given their potential to eliminate well-documented frustrations that physicians have with their electronic health records.

Third, building a more clinically relevant electronic health record system should incorporate artificial intelligence that can synthesize anonymized patient records; combine them with the medical literature, and provide insights at the point of care. Artificial intelligence, neural networking and deep learning were unheard of at the beginning of the HIT age. Now we have the computing power to perform this kind of analysis, the anonymized records to study, and vast swaths of digitized medical literature. Now it’s time to make better use of them. Though this may sound ambitious, there is encouraging work being done.

For example, a collaboration between Google and three academic medical centers — the University of California, San Francisco, the University of Chicago, and Stanford Medicine — is testing the ability of artificial intelligence to analyze raw electronic health records and generate accurate predictions about patient outcomes based on 46 billion pieces of anonymous patient data. While early in development, this effort has shown promise and could one day help physicians extract greater value from their electronic health records. Even so, this initiative and others like it must contend with fundamental gaps in our health care system’s IT infrastructure.

Issues of interoperability and user interface optimization have been successfully addressed in industries as complex as aviation, telecommunications, and banking. You can easily withdraw money from any ATM in the world because the industry came together to design secure systems that would talk to each other to satisfy consumer demand. These examples provide valuable lessons and hold out hope that the health care sector will achieve its long-awaited transformation.

Electronic health records lack tools to improve clinical care - STAT: To make electronic health record systems clinically relevant, they need artificial intelligence that can help provide insights at the point of care.