To date, there is little quantitative research on how providers use Electronic Health Record (EHR) systems in real clinical settings, and on the methodology and metrics to assess EHR usability: the effectiveness, efficiency, and satisfaction with which users can achieve intended tasks. Such research can identify candidate components for redesign. In particular, documentation of the patient encounter and information retrieval of existing patient data are complementary tasks of the clinical workflow at the point of care. Documentation is often in narrative form stored as unstructured text documents. Providers also retrieve information from previous notes. Lack of EHR automation and poor user interfaces can contribute to the introduction of redundant information into the patient record (eg, information copy/pasted from other areas of the EHR) as well as to inefficient workflows such as the duplicative work that results when clinicians enter orders through structured menus and subsequently manually document these orders in progress notes. In our previous research on time-motion studies in an outpatient setting (PACE study), we found the following: (1) inefficiencies in EHR workflow during the constrained time frame of office consultations. These can be classified as resulting from (a) navigation: providers move across screens to retrieve and then mentally integrate scattered patient information; (b) order entry: driven by nested pull-down menus and other inefficient interfaces, and (c) documentation: notes contain redundant information copy/pasted from earlier notes or other parts of the EHR, duplicative documentation of orders entered, poorly searchable notes, and boilerplate- generating templates. These contribute to information being lost in a sea of text. (2) The CPRS/VistA Notes function accounts for about half of total EHR activity and is quantifiably a central nexus of activity because providers repeatedly navigate back to Notes for reference (together, Notes and order entry tasks account for 20 ~75% of workflow activity, based on time-at-task, mouse activity and navigation patterns). Therefore, Notes is a promising candidate for redesign. (3) We observed wide variation in providers' EHR workflow and in how they organize information in progress notes, which deserves further study. The proposed project has 3 specific aims: (1) To measure longitudinally the degree of redundancy (primary outcome measure) introduced over time in patient documentation, and to perform baseline content analysis to study variation in how clinicians organize and segment their notes into major sections (eg, SOAP). We will also study lexical and terminology variation across providers.
This aim i s based on sequence alignment and manual coding of time-indexed archival CPRS/VistA progress notes from two VA sites. Clinician interviews (Stimulated Recall) will provide context for the findings. (2) To quantitatively profile how primary care providers use Notes and the EHR for documentation and information retrieval tasks (eg, which components of the note are newly entered by providers, copy/pasted, or boilerplate? What EHR components do providers access to source existing patient data elements imported in Notes?).
This aim i s based on existing time-motion data captured for our PACE study at one VA site. (3) To develop and evaluate the ActiveNotes software systems for more usable documentation and order entry system at the point of care. ActiveNotes is a VHA-sponsored project (hi2 initiative). ActiveNotes is an enhanced text editor that uses a technology stack based on parsers to interpret clinicians' input. ActiveNotes uses dynamic layout and hyperlinking to reduce redundant information and optimize documentation and information retrieval tasks of both structured and unstructured EHR data. Formative usability evaluation of prototypes will be iterative and integrated into the Agile development process. Feedback from clinician end-users based on test data, as well as input from other stakeholders, will guide system design decisions.

Public Health Relevance

The proposed study uses ethnographic, usability, and content analysis to study how clinicians use unstructured documentation functions of the CPRS/VistA electronic health record (EHR) during outpatient clinical consultations. The study focuses on how redundant information is introduced into progress notes and how this affects EHR usability and integration in clinical workflow, both of which are fundamental challenges to meaningful use of EHRs. The study, which is largely based on archival data, addresses knowledge gaps via quantitative and qualitative methods to profile how VA clinicians use computers at the point of care and to provide usability metrics. In addition, study findings will be applied to system redesign via the development of a prototype software system designed to minimize redundancy and improve usability of documentation functions. The study will leverage input from clinical users and operational stakeholders in ongoing VHA initiatives involved in development of next-generation EHRs to complement or replace CPRS.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR-3 Methods and Modeling for Research, Informatics, and Surveillance (HSR3)
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VA San Diego Healthcare System
San Diego
United States
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