Improving the EMR Experience

1. Improving the EMR Experience Approaches to Improving Decision Making, Evidence that Shows These Work, and How to Make Changes Seth Scott

2. 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

3. 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

4. General information regarding design of CDS interventions

5. 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

6. 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–ShneidermanHeuristics • Many of these may apply to changes that we might make

7. 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

8. 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

9. Documentation Forms

10. 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

11. 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

12. 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.

13. Results

14. Order Sets

15. 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

16. 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

17. Key Data from Khajouei et Al

18. 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

19. Results

20. Alerts/Warnings

21. 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

22. 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

23. 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

24. One way changes have been done

25. Pneumonia care set

26. Where to start changes • https://hospitals.health.unm.edu/intranet/synerge3/req_forms.shtml

27. 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

28. Discussion And Questions

29. 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 DecisMak. 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. • KhajoueiR, 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