**Transcript of Cyberseminar**

**Timely Topics of Interest**

**The Orderly and Effective Visit: Impact of the Electronic Health Record on Modes of Cognitive Control**

**Presenters: Charlene Weir, PhD, RN; Jonathan Nebecker, MD, MS**

**January 14, 2013**

**The Orderly and Effective Visit: Impact of the Electronic Health Record on Modes of Cognitive Control**

**January 14, 2013**

Moderator:We are at the top of the hour so at this time I would like to introduce our speakers. We have Dr. Charlene Weir, the associate director for Salt Lake Informatics Decision Enhancement and Surveillance also known as IDEAS. It is a VA HSR&D center. She is also the associate director for education and evaluation for the geriatric research education and clinic center known as GRECC in the VA healthcare – I am sorry, VA Salt Lake City healthcare system. Joining her today is Dr. Jonathan Nebeker and he is a core investigator also at Salt Lake City Informatics Decision Enhancement and Surveillance, VA HSR&D center, the VA Salt Lake City healthcare system. So at this time I would like to turn it over to Dr. Weir. And Dr. Weir, you will see a pop-up that says show my screen. Go ahead and click on that. Great now just head up into slideshow mode and we will be good to go. Perfect, thank you. Charlene, do you have your line muted? 

Charlene Weir:I do have my line muted and I apologize for that. Hello everyone. I just want to say welcome and appreciate the opportunity to talk about this topic. It is something I’m interested in, have been for a long time and have been working with Dr. Jonathan Nebeker a long time on this as well. So we are going to split the presentation. He is going to begin the presentation talking about the theoretical background. And the theoretical background actually was the foundation for a larger AHRQ grant that Dr. Nebeker was the PI on. And so it lays the foundation for this particular analysis of the results. So I am going to turn it over to Jonathan. 

Jonathan Nebeker:Thanks. So go to the next slide. So we will be – this is the overview of the – what we are going to cover today. I will be talking mostly about the first two items. And then Charlene will take over for the rest. And I have actually got to go to another meeting about how to put this stuff into action as we design the IHR systems to replace CPRS and VISTA or not VISTA but CPRS. Next please. So there we go. And so the overarching goal of this is for the last point on this slide and medical care is information intensive, current user interfaces are hard and unpleasant to use, at least many of us think so. And so the – we just need to get – think about information environments to improve the efficiency and the quality of care. And so we measure efficiency in terms of time which is relatively easy. 

But quality is difficult to get at. And if we measure – everybody I think on this call knows that to measure patient outcomes takes big studies and there are messy determinants of patient outcomes. And so we need to get to some surrogate outcomes for the effectiveness of these medical record systems. Instead of getting circuit outcomes or patient outcomes, we believe that in order to enable rapid and targeted productive development of these user interfaces we need a model to predict and measure effects of the user interfaces on the quality of clinical reasoning. And so that is why we are doing all this work. And then the main point of the study was actually to develop a user interface and maybe some other day we will present that. Next. 

So the – what is curious about this is the joint cognitive is the reason this paradigm joint cognitive systems. So the keyword here is that it’s an interdependent emergent system. And the – and so the cognition is distributed across the system so the computers do some thinking. People do thinking. The environment contributes to some of the so-called thinking of what is going on. And so some of the dimensions of this are goal orientation, so to increase the alignment of what – we are – everything is doing to what we want it to do. And then there is this concept of orderliness and control that Eric Honagle who is one of the – well, probably the proponent of this brand of joint cognitive systems, in that we want to – everything – if things operate smoothly towards their goals then that is one measure of a desirable outcome. And so again important to recognize that as the collective energy of this system is not just the parts of the system acting in isolation. So the next slide I think we have some contrast to illustrate that. 

Oh so here is – so here is an example of how the current EHRs contribute to bad orderliness, disorder of thinking. This is a little snippet of a study by Vanderbilt where they have looked at all the transitions and transition probabilities and the time spent in various tabs of their electronic medical record. And it is just a mess going back and forth, back and forth. Not good for thought flow and workflow. Next. And so again here are some things that to kind of keep in mind as Charlene goes over the talk is that we are talking – we are focused on cognitive support and we contrast this with decision support. And so we are looking at the quality of reasoning, not the right answer. So we are not looking for a mathematical right answer based on evidence. We are looking to generally improve the quality of reasoning generally. So again joint not separate systems. So it is not what the – helping the human do what the human does but helping the human do what the human does best and the computer do what the computer does best. It is helping the human and the computer work best together to accomplish the task. 

And so again – so finally a lot of what we are talking about here is cognitive and social psychology. And which overlaps with but in this case is not identical with ergonomics. And so we – and so with ergonomics typically you look for response times in milliseconds and we are looking at sort of how people work over seconds to minutes and how the thinking is happening in that time period. Next. And so this is just an adaptation of some of Honagle’s work in joint cognitive systems for medicine where we have stuff that is going on out there that affects – and the healthcare of the patient on the right hand side that creates events. And then that modifies these events when we detect those and can measure those, modifies our collective understanding of the health of the patient. And then we think about that and we determine a care plan and that produces more events. 

And the dotted line in the middle is of interest because if we can project forward, if we can give an information environment that allows people to better project forward we can reduce oscillations and get to and have a more orderly approach to the visit in this case and Charlene will illustrate some of the measures we’ve discussed for that. And so then these are the determinants, the components of the conditional control model. So goal interactions and the degree to which goals are defined and integrated. So sometimes goals conflict when you have someone who needs a diuretic for their blood pressure as a first line treatment but they get orthostatic hypotension at times for that. Or they might have gout and you may need to give them a thiazide. You may be increasing their tendency to gout attacks. So that is an example of goal interactions. And then you can also have a goal interaction where two things can – you can slightly modify your therapy and have a more elegant approach where one pill might address two different conditions. 

Time horizon is the breadth of information changing over time and future forecasting. So this is looking back in time at what is going on such as measuring blood pressure for multiple visits. And then also kind of thinking about what is going to happen in the future if I change it direct. Assessment of uncertainty. This is a kind of a new one that we have put in here and it is based on a lot of work out of Michigan on uncertainty. And so it is – and so it is important because of all the high degree of uncertainty in medicine we have added this dimension to the contractual control model. And then finally decision heuristics. This is how you might decide to do something in range and maybe the next slide kind of illustrates this. So this is the table that puts it all together. 

So decision heuristic, you can have this sort of random where over on the far right hand side where people are in scrambled mode so we organize all these various components into summary modes of control. And this again is following the contextual control model. And so we are – like you are watching medical students run a code, might be somewhat random patterns. Matter of fact we actually did have some scrambled sort of random as far as we could perceive, random actions of an intern evaluating the patient. And then opportunistic is just very quick heuristic tactical looking at guidelines. And then strategic is where you have heuristics that go beyond the guidelines and try to integrate the whole situation while accounting for the guidelines. You can see here the matrix of how it is probably best to look at the top line to get an idea of what the highest level of control is and then you can just figure either parts of that control that the rest of the modes address. And I think Charlene will be addressing this a little bit more later on. And so that is my part of the study. And I will turn it over to Charlene. 

Charlene Weir:Thank you Jonathan. And good luck on your next call. So now I am going to go over the actual study where we instantiate or operationalize these ideas into some of the work that we did with actual clinicians. And I want to emphasize that it is – it was our goal to try to figure out what is actually happening with using the EHR on clinical reasoning in a visit. And my overall thoughts on the issue are that clinical reasoning and communication and collaboration are very high-level cognitive functions. And sometimes when we measure the impact of decision support or EHRs we tend to measure them at low levels. Like for example, if somebody remembers to do something or if some action needs to be done. But the very high level sort of that diagnostic reasoning, planning, and coordination is not often measured unless you get to the far extreme of patient outcomes. 

So in this case our – we had two hypotheses. And I apologize for those of you who might find research not so interesting. I am – this talk is a bit formatted in a research format. But I hope to make it applicable to actual practical situations. So the first aim is that the intensity of pre-visit planning would differ – this is our hypothesis. That the intensity of pre-visit planning would differ as a function of the performance level. In other words, performance is measured by what Jonathan talked about, these four levels of control, strategic, tactical, opportunistic, and scrambled. That more pre-visit planning would be associated with – it would be more likely associated with strategic levels of control. The second aim is that higher level of performance would be associated with lower frequency of searching in the EHR during the visit. And these are pretty simple hypotheses but the idea is that something about the way that people use the EHR makes a difference in their performance. 

It is a correlational descriptive study. We did not manipulate anything. We do not – it is not a randomized trial. This study is part of, the first part observational, of a larger study where we develop metrics and measurement tools to do a simulation, which is something Jonathan referred to and will be reported later. We had five VA hospitals, forty-five primary care providers, and what we did was – in actuality is we went and consented the provider and the patient. We sat in the visit room with a tablet and a tape recorder. We tape-recorded – we did an interview prior to the visit with the provider asking them to think aloud while they planned for the visit. And we watched what screens they went to and what they did and that was called phase I. And phase II we actually were in the visit room trying to be discreet and would capture screenshots manually. 

Basically we had a tablet where we could just click on a – when they moved to meds or notes or consults we could – we could click on the screen and capture that movement. And then we did a post-visit interview. The result – we did some qualitative results of those visits but the – this study is actually focusing on the quantitative part. So the key part to this whole study is the measurement part. And I am going to take a little bit of time to describe this – build on what Jonathan already talked about. So we have all had a sense when we visit the doctor or when we interact with a patient ourselves when it is orderly and controlled. And what that means is that we go into the visit with a sense of what we want to accomplish, what issues are most salient, what information we need to capture, and we move through that interaction relatively smoothly although, of course, patients bring up new things and stuff like that. We’ve also observed, especially in trainees and in ourselves when we are not – when we are out of sorts that sometimes, or if there is a lot of distraction that the – it does not go smoothly. 

We forget to bring information into the visit. We have to search for things that we cannot find. We start to make a decision without enough information and we have to backtrack and go find that information. And so – so the degree – our concern here is the degree to which the electronic record supports sort of an orderly visit, a high level functioning of the interaction between the patient and the clinician. And Honagle talks about that in terms of control and orderliness which is actually a nice concept because you can see in a well-run system people know what they want to do – what needs to be done, information is where you need it, and when there is a lot of anxiety, stress, or lack of information it does not run so well. 

Now the thing about the strategic level is that it goes beyond what most people think in terms of an effective visit. An effective visit might be thought of as well, you covered all the preventative care issues. You cover all of the diagnostic issues. You deal with the patient’s preferences. And but there is a certain roteness or script to the process. So strategic actually does all of those things but goes beyond. So the patient’s preferences are incorporated into the integration of the [inaudible] the patient has. The hypertension problem, for example, is looked at across time, both in the past and in the future and how it links to the patient goals. The medication interactions are integrated with the workload pattern as well as what the patient wants as well as what the diagnostic concerns are. So there is a level of integration high level thinking that is apparent. And the tactical is fairly structured, rigid, more guideline based. 

And a tactical visit you could see – what you see often is that people go through the preventative care, clinical alerts, and then they go through the medication reconciliation. Then they go through the problem list in a very sort of structured way. And occasionally if a patient brings up something that pushes the provider out of the script line sometimes those things are even ignored because they are not part of the script. Whereas in a strategic mode that there is a higher level of attention to variety of things including what the patient brings up. In opportunistic mode, the visit is more scattered. It bounces from highly salient issues to highly salient issues. So a patient brings up a topic. The provider listens to that then fails to move back to their more structured orderliness. And then they move onto something else that captures their attention. 

And so at the end of the visit there is a tendency to try to catch up to things that are forgotten or stray pieces, lines of inquiry. And sometimes things are forgetten – forgotten, excuse me. And there is a lot of in, what is the word? Unstructured interaction with the EHR. And then scrambled this very unstructured chaotic – those are very extremely rare, as you will see in the data mostly from novice interns. Now that – so those – that measure of control mode is measured by looking at the transcripts of interviews. And so it is – in some ways it is a descriptive qualitative coding event. And that requires taking these dimensions, stripping them down to specific rules, having independent raters read those transcripts, see if we can get high interrater reliability on the rating of the visit. And that is what we did. 

Actually, it is not that difficult to get interrater reliability on this. It is actually – they are more differentiated then you might at first think. Pre-planning intensity was a variable coded on a one low to seven high scale. And it was coded by a different set of raters, not at the same time as the visit itself. And so that part of the transcript was separated. And what that consisted of was the degree to which the provider would sit down, read all the prior – their prior note, maybe the prior notes of any intervening visits, any emergency room notes, and then what they most – at the very high level of planning what you would see is they would construct a new note, sometimes and often copy – they would copy and paste their old note. Paste it into a new note and then systematically bring in new information that was structured in a way that they could use it during the visit. 

It is very interesting to look at these notes because what they do is they take data like colonoscopies and they put them all in one place so that they could look over time the results of three or four colonoscopies, for example. They highly structure the notes so it brings forward the information that they really want. That is probably the highest intensity of pre-planning. And then the third variable of interest here is the searching activity. It is the proportion of overall screen changes dedicated to searching alone. So we divide – when providers are in the room talking to the patient they are looking for information they cannot find that was recorded differently than if they were doing screen changes based on entering orders or notes. This is the same matrix as Jonathan talked about but it is reversed. So this is just a way of looking again at how we operationalize the control modes. 

And if you look at the first column called strategic, you can again see the dimensions we were interested in. And just to make clear, a person could be – a clinician could be talking to a patient about their hypertension or their blood sugar and if they spend some time looking at trending information or if they put that information in their note prior to the visit that was considered a strategic strategy. Uncertainty orientation or recognition is also very important because to the extent that the clinician might say I do not know – I do not have enough information about this. I am not sure about this concern. And they attempted to follow up on it. It is a meta process which they would do during the visit and very important for care, we believe. So I will go – I will move on from this. I think we have covered it. 

These are the results, descriptive results. And basically this is the number of clinicians distributed across this matrix. Whether or not there was a relationship between mode of control and the years in practice. So you can see that actually, as years go up in practice they were more likely to be using opportunistic or tactical. And there was no difference in terms of role. In fact, there was some difference in terms of work pressure. There was a variable that we asked them to what extent were they feeling some work pressure. And you can see that those clinicians in a – were participating in a visit that was opportunistic and tactical tend to have higher work level pressures. And the time allotted to the visit was no different. This is a distribution of the overall percent of cognitive modes overall. Fifteen percent of the visits were strategic. Tactical were about thirty-nine percent. Opportunistic, forty-six percent. Almost fifty percent were a bit unorganized. 

The mean number of screen changes per visit was eighteen point five, which is quite a bit actually. There was a lot of – sixty percent of those were searching screen changes. And so just to make the description a bit vivid what you would see is somebody going –talking to the patient face to face using a very collaborative interaction with the patient and the computer. But then because they needed some information, they could not find the last procedure results or something that the subspecialist had recommended on their consult they would be searching through notes and searching through procedures and searching through consults and labs. And so [LAUGHTER] their back would then turn to the patient and they would be spending a fair amount of time searching through the EHR looking for something that they had not prepared for before the visit. 

And this is sort of the – is not the – these other – these are other variables that we related. Familiarity with the patient was one of the issues that we were concerned about. Mental stress was another one. And so these were not correlated. Now these are the cognitive task analysis instructions just so you can kind of imagine what they were being asked. Please think aloud what is in your mind while you do this task. Indicate what you are trying to do. There are no right or wrong answers to say. Now for those of people on the line who are interested in conducting these kinds of studies, it is very difficult and maybe even not appropriate to ask clinicians to think aloud while they actually do clinical work. So they would try to do it to some extent but then we would – once they were done with a task we would then probe to see what they were doing or what they thought about what they were doing. 

The use of templates was extensive and so we wanted to make sure that we understand what they were doing in the templates and why. And I have already gone over some of the coding protocols for intensity of preparation. Key things about that preparation that I might not have addressed so far is that medication review – medication review is probably the most common and most time intensive part of the visit. And so they spent a lot of time making sure that they understand what the patient is taking. And then they do a pre-review of prior visits and intervening events. Some clinicians only look at their own – probably eighty percent of clinicians only looked at their own last note and if there was an ER visit. And then a small, much smaller segment, would look at a few other progress notes. 

It is a bit of an illusion. I mean, it is true that the progress notes and access to the other clinicians’ notes are made much more available with an electronic health record. However, because there are so many to go through and you have to read them all it makes access difficult. They cannot review a problem across notes very easily, for example. And the thing – the key thing that would also happen in the pre-planning preparation was the degree to which they establish goals of visits. So these are sort of the criteria by which we looked at intensity of preparation. These are results of the statistical analysis regarding the intensity of pre-visit planning and whether or not that would differ across performance mode. And we found that indeed it did. There was a significant relationship and the key point for that is – it was still significant after controlling for years of experience. In other words, those individuals who had worked for a long time were not any better – that relationship between pre-visit planning and mode was not any stronger for that group as well. 

This slide has a visual presentation of this data. And you can see by inspection that – that the tactical – those visits that were tactical and strategic were about the same in terms of pre-planning. And it was the opportunistic visits where pre-planning was low. And you can see why – what – since this was not a randomized trial we could not tell whether or not pre-planning worked or not. Pre-planning was a function of both the provider and the visit. If it was very busy the amount of pre-planning available to a clinician, the time available, was much lower. The thinking here is that if they have less time to pre-plan and set up a note for themselves then they are likely to have a more opportunistic visit. And just for clarification, what this means in practice is if a clinician was – had the time to set up a note prior to the visit and organize their goals of care and the associated important information around problems then all they had to do during the visit was to put up the note. And they would then have the freedom and flexibility to simply talk to the patient, look up at the screen, and get the information they wanted. 

It is when they had to stop and start searching again in the EHR when the flow was disrupted and then – and they would have to find information. So the more of that kind of searching that was associated with lack of planning created a more opportunistic visit. That is basically our hypothesis. For the second aim, we were looking at the level of performance mode in the visit. And what – whether or not it was associated with searching during the visit. And this is basically what I was alluding to earlier. So higher levels of performance mode was associated with lower incidence of search activity. And you can see that in the results. And this was true again even controlling for pre-planning. What this means is that even after you control for pre-planning, even after you did the pre-planning, if for any reason you had to stop the interaction with the patient and start looking for information, maybe a patient brought up a new topic, maybe they were – had special concerns about depression or other issues, if that was the – if that was the case then the flow of the visit was interrupted and they may need to search through the EHR. 

Since I did about half of these observations myself this is a – I remember seeing this over and over again. There are many times a patient comes in, brings up a topic that they – was new to the provider and required some sleuthing. Sometimes it was obvious sleuthing like looking on the internet for causes of – or looking for services. But the most difficult sleuthing was looking for clinical information in the EHR. And it would interrupt the flow of the dialogue and it would take time away from the patient/provider interaction. And this is the operate – this is how we operationize search activities which I have already covered to some extent. This is one of the limitations of this study in that we did not have a software that was capturing screen changes automatically. We were in the room capturing them as they happened and we observed them. Although we did position ourselves so we could observe them. Rooms are pretty small. We could do that. 

By the way, for those people conducting this kind of research, we did not have any patients refuse nor did we have any providers refuse for us to be in the room which – which speaks to the general favorability that VA patients have on research. This is the result of that aim in terms of search activity. And these bars represent the proportion of screen changes that were related to search. And you can see again that the tactical visits and the strategic visits were pretty identical and that the proportion of screen changes related to searching was probably, I do not know, twenty, a third higher again for the opportunistic visits. So clearly searching around in – during the visit was associated in a correlational way with sort of a scattered flow during the visit. 

On this next slide we are just focusing about screen changes related to entering or ordering. And in this – this kind of is a way of confirming our overall approach. We had visits rated at a higher level of control, higher performance had a higher proportion of computer interactions involving ordering. What that meant that they were – they were more likely – if they were doing screen changes it had to do with designing and ordering therapy. And again it was – this remained true even after controlling for pre-visit planning. You can see this in the bar chart here, the proportion of notes or I mean, proportion of screens associated with entering either orders or progress notes were pretty high for tactical visits and strategic visits and were much lower for opportunistic visits. There is a dependency here because we are talking about proportion of searching and then screen changes that have to do with searching and then proportion of screen changes that have to do with ordering. 

So these are sort of in some ways mirror images of each other. I also want to take this point, this time right now, to make the point that these are attributes of the visit. It comes from our general point of view that this is a joint cognitive system, that it functions in an orderly or non-orderly process as a result of how all components interact with each other. So we are not making the case here that some physicians or clinicians are strategic and some clinicians are opportunistic. We personally have all had the experience of being extremely busy and having to go through our interactions with patients in a very fast and sort of heuristic way. And we have also had the opportunity to be able to take a little bit more time and be more thoughtful with the interaction. So time availability is one component and the other component is for our purposes here is a degree to which the information is available and organized. And that is what we are trying to get at here. That we think it makes a big difference in terms of the clinic – the process flow inside a visit. 

So I have some conclusions and then I can go to questions. So the first conclusion is the pre-visit preparation of electronic note was significantly associated with higher levels of visit controlling after controlling for years of clinical experience. It is my personal observation that those clinicians in the VA who have been here a while are the ones who seem to be more likely to use very sophisticated methods of planning for a visit. And what I mean by planning is basically constructing these notes, these pre-notes – and because it was the only way to put together in one screen all of the information they needed to support what they thought the visit was about. It does serve two purposes. It means they reviewed the chart so they are familiar with what the patient situation is, and also means that the information is available. Searching activity was significantly and adversely associated with visit performance. So what this means is that, and as I have already pointed out, is that searching during a visit is interruptive, it is disjointed, and it interferes with the flow of thought processes for the clinician. 

Now this work, of course, is suggestive. We did not manipulate anything and we have a – Jonathan has a study that will be coming out where we actually manipulated something in a simulation sense. But the – but the point is that if we want to improve the EHR what we – we need to do is improve the integration of information available at any particular clinical event. And the other point that I want to make about that is that the integration of information is idiosyncratic to some extent. So – so we need both the default or background information that would be, for example, integrated about problems displayed in one place. But we also need to provide tools for clinicians to adapt that information to their particular needs for that visit for that day for that patient. 

And then we might imply that the EHR is not providing adequate cognitive support for visit workflow and that is kind of what I have alluded to just a bit earlier that information has to be very organized to support a complex primary care visit. It is – you really cannot feel like it is enough of an organization to have it available by searching through tabs or... A very common problem that occurs in primary care visits is the reason why a medication was discontinued prior or a reason why it was ordered. And in order to find that out a clinician has to read – they have to figure out when the medication was originally ordered. That in itself is a very complex task. Then they have to look back on the notes to see or look back on. Looking for the provider who ordered it to see if they can find the note where it is described why that was discontinued or ordered. Then they have to read the note, which could be as long as five pages long or skim it rapidly to figure out if that medication is actually in there somewhere so they can make that discernment. It is not a task you can do during a visit. 

So there are so many information decision tasks that have to be done during a visit that the EHR does not support. Another example is it does not support patient preferences very well because patient preferences are embedded in text. And they are not even labeled as patient preferences necessarily. So skimming through other people’s notes would be a time consuming issue. So basically what happens is patients are asked again what they want to do and not to do. And sometimes I think patients wonder don’t you guys have a computer? [LAUGHTER] Anyway so then – and another example is a functional status. Functional status is by and large pieces of information that is embedded in text. And despite the fact that the client functional status is a very good predictor for other negative outcomes for patients finding a decline which means finding a trend in text information is very difficult. So unless the provider is willing to go through notes beforehand and build up a representative display of how the patient has been changing over time in one note then they – they cannot get that information at a glance. 

There has been a debate in the press and media recently about the ability of clinicians to copy and paste notes. This pre-preparation that we were talking about is dependent on the ability to copy and paste notes because they are building up a display that is unique to this visit, to this time, and to this patient. So if they could not copy and paste I do not know that they would be able to adequately do their pre-planning. Anyway, those are some thoughts on this result. And I think I am going to conclude and make it available for questions. 

Moderator:Excellent, thank you very much Dr. Weir. We do have a couple pending questions. And for those of you that joined us after the top of the hour, to submit a question or comment simply go to that go to webinar dashboard on the right hand side of your screen, type in your question or a comment under the proper section, press send, and we will get to it in the order that it was received. So this first question is a little bit long. It has some comments and a question embedded in there. So I will just go through the whole thing. As someone who believes in user interaction test this confuses me. Is the interaction between the provider and the EHR or between the provider and the patient? The patient appears to be lost in this. A major objection to electronic records is that it distracts the provider from the patient. This does not seem to be addressed by the study. 

Charlene Weir:That is a great question and I think I made one small allusion to that issue but I can actually expand on that some more. There are two ways that we incorporate the relationship to the patient in this study. One of the coding criteria for a strategic performance mode of the visit is the degree to which patients’ preferences and goals are incorporated into the visit. So those things are actually coded for. If you recall what we are coding is a transcript of the visit. So we hear the patient said, I mean, we read what the patient says; we read what the provider says. So we are coding to the extent that if a patient brings up that his daughter lives with him, has moved back in with him and her four kids and it is driving him crazy but the provider does not pay attention to that, says, “Oh, that is too bad,” and moves on. Or if they complain about a pain that is not related to a particular diagnosis and the provider does not pay attention to that that is – they are given sort of negative points in terms of the performance mode. 

So even though it does not look like the patient is involved in this they are very tightly involved in that in terms of the coding protocol. The second issue is that having been in the room on these visits, we did not actually code the degree to which a provider would sort of turn his back on the patient and go to the computer. But if you can imagine that any searching activity in the EHR results in exactly that. You have to turn to the – your full attention is on the EHR and you’re searching for information, click, click, click, looking for [laughter] something and the patient is not attended to. That is why it is so interruptive. Those visits where there is a lot of pre-planning where all they have to do is look up at the screen at the information about the history of a lab result, a medication, whatever they can they just look up and read it on their pre-prepared note. Those visits there is a lot of face to face interaction with the patient. It is very clear. And if you talk – when we do the interviews when we are asking why in a cognitive task analysis, why are you preparing the notes this way? What are you doing? What is the goal? What do you expect to achieve, et cetera? They all say that they do that so that they can put their attention to the patient. That is it. 

Moderator:Thank you for that reply. The next question we have: what are your thoughts about bringing into this model a way to give the clinician a heads up about the patient’s current concerns so that there will be more opportunity for a strategic visit? It would be very great if clinicians knew in advance what the potential patient interruptions were going to be. 

Charlene Weir:That is a good question. I had thought of that. There are a number of studies and workflow situations where people sort of capture a chief complaint or they do a functional assessment prior to the patient getting in the room. From my observation of different clinics, I do not know, for different reasons I have watched clinic flow in a large number of VA centers, and in some centers the flow is such that the nurse interviews the patient, sort of does a heads up with any kind of particular concerns and sends a note to the clinician which they can see. Writes a note and then the clinician can see that when the see the patient. Or they write something down or verbally give that information to the provider. So if a nurse, for example, can screen and talk to the patient before they see the provider then I think that is probably the best solution. Because in those situations the nurse can kind of drill down to what the information is. 

In the other settings the nurse actually does not see the patient until after the clinician has seen them and they might be doing some education. And in other settings the nurse does not really see the patient at all. That would be an LPN intake to do sort of vital signs and stuff. So I think it is a workflow issue. But I do think there are some possibilities for capturing electronically some of these concerns. Also I do know that in some settings patients are called the day before to be reminded to come to the visit and that might be a time to capture current concerns. So I do not think there is any way to get away from human to human interaction on this mostly. [laughter] 

Moderator:Thank you for that reply. We have a couple comments from one of our attendees. The total time that it takes to do this averages out to be a lot depending on the thoroughness of the prior day pre-review. It is exhausting combined with the amount of time for daily alerts/paperwork we get in we get in primary care. It is rewarding, though, in all other aspects. 

Charlene Weir:I would like to address that comment because I see the pre-planning activities that the clinicians are doing as an adaptation to a clumsy system in some ways. And it is exhausting. The way it works the smoothest is you have a patient, you’ve known this patient a while, you’ve built up a progress note that has all the information that you’re tracking that you can sort of delete issues that you’re not addressing anymore, add issues, put in new information so that the pre-planning aspect is minimal. You have a workflow issue so that the nurses bring up new topics. You – some of the clinical reminders are done by sort of the intake and some of them are done by the clinicians. 

But in some settings clinicians have thirty-five clinical reminders to go through in a visit. I mean, I know this is probably the top number but it is astounding how much that kind of work is. And that – that is not the same kind of work as when you have to sort of listen to the patient, figure out – integrate their current concerns with their current clinical status. And that – which is a much higher level processing than the clinical reminders. So – and the medication reconciliation is another one that can be looked at as sort of a paper pushing thing or if it was done right would be integrated under a full flow of the interaction with the patient. So it is exhausting. It is a lot of work as we go on. 

Moderator:Thank you for that reply. This is the final question that we have at this time. To what extent has this information been shared with PACT – with the PACT program? Does the PACT evaluation identify PACT visits by strategic, tactical, opportunistic, or scramble? 

Charlene Weir:We have only indirectly shared this with the PACT program. I have attended a couple of meetings on the information technology planning side of the PACT when it first started. And we have in different kind of VA settings have interacted with the PACT implementation. So they do not use this mode of looking at visits. It does – it is a fairly high – as a measurement model it is – it is rather intensive because it requires human coding. It – it is possible at some point to extrapolate this into something more automatic perhaps. And the key – the point that we wanted to make with it is to show that – that we could do – we could use it as a method to evaluate interventions to improve information availability and coordination and so it could be, as you said, used as a pre, post or a PACT intervention but not as an ongoing clinical data point unless it is automated. [crosstalk]

Moderator:We do – 

Charlene Weir:So the answer is only partially and informally. But it is a good point. 

Moderator:Sorry to interrupt there. We do have a couple others that have come in. The first one – oh somebody is asking about what is the PACT program. 

Charlene Weir:Oh it is a patient aligned care team, sorry that we did not explain that well. We used the acronym. It is the VA’s approach to developing and implementing a medical home model. And for those of you who are new to the concept of a medical home in clinical care it has – it has been a movement that started off in pediatrics and other areas but it is considered to be a model way to do business in clinical care for nearly everybody. The idea is to bring all services related to the patient in one setting. And so a team works on the clinical care of the patients including social work and psychology and occupational therapy, anything that is related to the patient. So there is a coordination and distribution of the – the interventions and care for that patient across a team. Requires a lot of care coordination within the team. It is also there is a lot of emphasis on patient preferences and goals. So the VA did some demonstration sites and has been organizing to implement this and has been implementing this nationwide. The idea is that there are other research that has shown there are better outcomes for patients under a medical home model. 

Moderator:Thank you for that answer. Also I am going to plug our cyber seminar for the PACT series. We have it every third Wednesday of the month at 12:00 pm and you can also visit the archive catalog for several PACT cyber seminars we have had. The final question we have at this time: what changes to the interface can be suggested to improve the current EHR systems? 

Charlene Weir:This is a good question. It has I think it is more than changes to the interface. It is changes to the integrated structure of the EHR underneath the interface. That is one thing. Medications need to be related to reasons why they are ordered and discontinued, for example, need to be related to disease entities. So that architecture is important. And the second thing is that tools, making it very easy for clinicians to put this information together rapidly is another thing that we should encourage and develop because they will do it anyway and why not make it very fast and easy, natural language processing, pulling out text, finding and pulling out text is reasonable, organizing information around events, timelines, extrapolating the multiplicity of views so it is easy to look by provider, look by team, look by timeline, look by problem and integrate the relationships between the events like lab values, problems, medications. 

A simple thing is that medications are monitored usually by lab values in many cases like kidney function, creatinine, et cetera. These things should be easily queried and linked together without having to do much work so that questions, even if you find yourself having to answer questions in the visit room it should be rapid. And there also could be these sort of multi-factorial displays available for quick views to share with the patient as well. I mean, for example, how your blood sugar is related to your exercise is related to your weight. 

Moderator:Great, thank you. That is our final pending question at this time. Would you like to give any concluding comments? 

Charlene Weir:Only that I think that this is exciting work. And I think the VA can maintain and extend its leadership in this area. We have a lot of experience dealing with electronic medical record and the positives and negatives and issues involved in it. And so Jonathan’s work on the IEHR with the Department of Defense is one of those new extensions. And so I just would encourage everyone to get involved. 

Moderator:Thank you very much, Dr. Weir, for sharing your expertise with the field. And thank you to our attendees for joining us today. This session has been recorded and you will receive a follow up email with a direct link to the archive so feel free to share that with any of your colleagues that were not able to attend the live session. As you exit today’s webinar you will have a short feedback survey that will pop up on your screen. Please take just a moment to complete those few questions. So thank you once again everyone for joining us and this does conclude today’s HSR&D cyber seminar.

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