Anticipated Impacts on Veterans Healthcare: The VA's electronic medical record (EMR) known as CPRS affords exceptional access to vast data resources across the VA network, but potential benefits are hampered because CPRS lacks adequate tools to navigate documents (notes, summaries and reports) when electronic charts contain many documents. All veterans' care will be timelier and better-informed when decision makers are equipped to rapidly access the essential CPRS documents needed for their work. Background: The EMR supports mental work of health care decision-makers, but its ability to assist is strictly constrained by limits of human cognition and workload. An EMR must present the 'right' amount of information or it risks overloading users with irrelevancy and degrading their efficiency and decision quality. Documentation overload is a negative consequence of the CPRS success. Patients in Veterans Integrated Service Network 20 with ten or more documents on file (72% of total patients) average 121 text documents apiece - more than a clinician will read in one encounter. Identifying relevant documents is important because decisions depend on documents that are read. The investigators' current project, HSR&D IIR 05-019, 'Assessing Information Value in Computerized Patient Care Documentation Systems' has identified several barriers to effective document review. An innovative web-based CPRS simulator developed in that research permits evaluating solutions to user interface problems without disrupting patient care or requiring EMR reprogramming. Objectives: This one-year pilot project will measure whether enhancements to the CPRS document system impact health care decision-making. Observations and approaches from current research will be extended to accomplish the following specific aims: 1. Implement CPRS document display enhancements suggested by cognitive work analysis of interviews conducted with 129 CPRS users in project IIR 05-019. 2. Measure the performance impact of the enhancements on decision-making that requires document review, using a web-based simulated CPRS testing platform. 3. In a proof of concept exercise, demonstrate the feasibility of linking the simulated CPRS evaluation platform to data in a VA research data warehouse. Methods: In an experiment powered to detect the effect of enhancements on decision speed and accuracy, 100 CPRS users (practitioners, nurses and administrators in equal numbers) at two VA sites will be recruited via e-mail to participate in a document review task typical of their work. Using the simulator, subjects will review manually de-identified CPRS documents for three cases and perform a decision task for each case. In a balanced incomplete block design, one case will show documents in a baseline view and two cases will be presented in enhanced views. Measured outcomes will be the time to complete the decision-making task and the completeness and correctness of the decisions. ANOVA will be used to test the effect of document enhancement. The proof of concept exercise will consist of programming a 'live' link between the CPRS simulator and a VA research data repository. This version will not be deployed for the research described above, but will be evaluated by the investigators for its feasibility as a tool to conduct iterative, large-scale, cognitively informed investigation of CPRS human interface design under a Quality Improvement paradigm.

Public Health Relevance

The electronic medical record (EMR) is the centerpiece of national health care reform policy and a cornerstone of VA's health care mission. Over time a successful EMR accumulates a huge volume of text making it difficult for doctors and nurses who use the EMR to find the vital information they need. The VA has been a pioneer in adopting the EMR and has accumulated more than a billion text documents for its veteran patients. This volume of information subjects VA employees to textual information overload and motivates the present study. The investigators propose innovative methods to study the impact of enhanced EMR text displays on health care employee performance. Identifying opportunities to improve VA EMR and employee performance will potentially impact the delivery of health care to veterans. VA findings will apply to the general population as American health care organizations adopt EMRs that are equally subject to eventual text overloading.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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VA Puget Sound Healthcare System
United States
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