The American Recovery and Reinvestment Act (ARRA) has profound implications for clinicians - they are expected to adopt and actively utilize electronic health records (EHRs), or be subject to financial penalties. One month after ARRA was signed, however, the National Research Council (NRC) concluded that the nationwide deployment of EHRs called for by ARRA might set back 21st century healthcare goals. The "central conclusion" of the NRC report was that current EHRs do not provide cognitive support for health care clinicians. Further, if clinician cognitive work is not supported, patient care and outcomes suffer. The latest research on EHRs suggests slow but increasing adoption rates, mixed results regarding quality of care and safety improvement, no reduction in costs of care, and physician dissatisfaction with EHR use. We propose that issues related to failed EHR achievement can be overcome by designing EHRs which support the cognitive work of clinicians. This premise is consistent with conclusions from the 2009 NRC report and two October 2009 AHRQ-funded reports calling for AHRQ to fund research on the relationships between clinician cognitive work and EHRs. This application takes up that challenge. Our long-term goal is to develop new EHR interfaces (data displays and input requirements), implementable by vendors and/or information technology programmers, that are demonstrated to support and extend clinician and team cognitive work to improve patient outcomes. This application takes the first step toward our long-term goal.
Our Specific Aims are to (1) identify the cognitive work requirements of primary care clinicians and their clinical teams, and (2) develop and test specific EHR interface design requirements that support these cognitive work requirements. We choose to focus our research on primary care because of its high utilization, high complexity, and the current national efforts to redesign it following the patient-centered medical home model. Due to the cognitive complexity of primary care, we will employ a method designed to study cognitively complex work: cognitive task analysis (CTA). CTA methods are well-developed, and have been used to determine cognitive work requirements and develop information technologies that support this cognitive work in other complex domains such as aviation, nuclear power, NASA - and recently - healthcare. Using a specific CTA method called Goal-Directed Task Analysis, we will map the cognitive requirements of clinicians and clinician teams to EHR interface design. Our experienced research team comprised of experts in human factors engineering, health information technology, and primary care, has an 11-year history of collaboration and is uniquely positioned to complete this important endeavor. This application builds on the successes of our team's three recent AHRQ-funded primary care patient safety studies, and continues our productive partnership with Wisconsin's Practice-Based Research Network, to recruit clinics and clinicians.
This study is relevant to public health because it seeks to inform the design of electronic health records (EHRs) to support the cognitive work of primary care clinicians and teams. If EHRs do not support clinician and team cognitive work, patient care and patient outcomes may suffer.