The Computer Will See You Now

Affects Doctor Affects Doctor

-Patient Commun

Patient Commun

Clinicians Patients

Exam Room 

Computers

Richard M. Frankel, PhD

Research Scientist

Center for Implementing Evidence Based Practice

Richard L. Roudebush VAMC

Indianapolis, Indiana

Jason J. Saleem, PhD

Research Scientist

Center for Implementing Evidence Based Practice

Rih d c

har

d L. Roudb h e

bus

h VAMC

Indianapolis, Indiana
Today s’ Presentation:

I. O i verv ew of this topic

II. The persistence of paper with the electronic 

record (data from completed pilot study)

III. Understanding variations in CPRS use amon

care clinicians (new HSR&D IIR grant)

IV. “Rapid ethnography ethnography” for evaluation evaluation of clinic

clinic

information systems in the field (the latest i

methodological development)

V. Concluding remarks
Background:

• Clinician Clinician‐patient patient relationships relationships central central to

ambulatory care

• Increasing Increasing use of information information technolog

technolog

health care.

• Increasing Increasing use of EMRs at the point of ca

the exam room.

• Potential Potential for IT to enhance enhance clinical clinical care• Concerns that IT could create barriers fo

relationship

• Limited information on IT effects on clin

patient communication
The Persistence Persistence of Paper with th

• HSR&D COE pilot grant• Alissa Russ, PhDSaleem JJ, Russ AL, Justice Justice CF, et al. Exploring Exploring the persistence persistence 

with the electronic health record. International Journal of 

Informatics. 2009; 78(9):618‐28.


Background

• We re’ going “paperless paperless !”• “Paper persistence” with CPOE

(Ash et al., 2007; Campbell et al., 2006)

• Workaround strategies to VA’s BCMA (Patterson et a

• Limitations of EHRs (e.g., Hatzband & Groopman, 20

– Copied, repetitive notes that desensitize clinicians to new, 

– Less attention directed toward the patient

• “Shadow” paper chart (Wears, 2008)• Lack of integration of health IT into clinical workflow 

• Visual organization organization of EHR data incompatible incompatible with cl

cl

delivery activities (Varpio et al., 2006)
Study Obj i ect ve

• Explore and understand human‐techn

integration factors ( g, e. . computer usa

and human‐computer interaction issuthe EHR level that may be causing causing hea

hea

workers to rely on paper alternatives.
Methods

• Semi‐structured interviews

– CPRS is designed to be used by a broad range o

healthcare workers

– N=20 (3 physicians, 2 pharmacists, 2 NPs, 4 RNs

techs, 1 dietician, 3 administrators, 3 IT speciali

• Example questions

– What paper‐sources do you use in your clinical work?– Have you ever experienced experienced frustration frustration in viewing viewing or combining combining 

from CPRS (e.g., patient data) during your clinical work? Exam

– Have you ever manually transformed patient data from CPRS o

better organize information during your clinical work? Exampl

– What is your ideal workflow during your clinical work and how 

to CPRS?
M th d e o s ( t) con .

• Inductive qualitative analysis analysis• Integrating findings across interviews 

emerging themes; recurrent paper‐ba

“workaround” strategies

• Two independent coders for all 20 tra• Series of six consensus meetings

– Development and refinement of coding s– Resolution of coding differences
M th d e o s ( t) con .

Generalizable Themes

Ill t ti C

Guiding Study Patterns Across Cases

Questions and 

Conceptual 

Frameworks

Raw Data

Illustrative Cases

Raw Data

Fig. – Data analysis and abstraction process [Roth Patterson, 2005], where higher levels in the hierarepresent a greater level of abstraction, ending ingeneralizable themes.
Results

Paper use with the electronic health record related 

following:

Efficiency (20) Task Specificity (12)Knowledge / Skill / Ease of Use (20) Task Complexity (9)Memory (17) Data Organization Organization (9)Sensorimotor Preferences (15) Longitudinal Data ProceAwareness (12)
Results

Paper use with the electronic health record related 

following:

Efficiency (20) Task Specificity (12)Knowledge / Skill / Ease of Use (20) Task Complexity (9)Memory (17) Data Organization Organization (9)Sensorimotor Preferences (15) Longitudinal Data ProceAwareness (12)
Efficiency

• Using a workflow process that improves actual or p

efficiency.

• Many of the cases related to ordering.• Example: The Emergency Department currently do

orders on paper.

– Phys –> Nurse –> Clerk –> Computer– The order is processed from the paper form b f e ore is get

the computer system
Memory

• Reminder about "old" or existing information.• Use of paper as a cognitive memory aid and disp

display device (Ash et al., 2006)

• Example: Pharmacist makes hand notes on printo

CPRS and transfers transfers the new handwritten handwritten data ba

CPRS later in the day. “The hand notes help me

remember. I do this for discharges and inpatient

can be 6‐12 discharges/day. It is not possible to 

these types of notes in CPRS [in real time]. I don

how you would do this in the computer computer... We nee

to do our job.”
Sensorimotor Preference

• Preferred sensory input for task

• Participants described a preference for the followi

mobility; ability to “h ” ear something; h ld o someth

“tangible”; something concrete to “deliver”; and/o

something something that can be easily manipulated manipulated (e g. ., ha

• Example: “I ‘hear’ the paper being dropped in my 

[ g indicating new unscheduled patient has checked iglance at the basket to make sure someone has no

piece of paper in my basket.”
Awareness

• Recognize new / important information: notify, ale

adjusting "signal to noise" ratio.

• E l xamp e: "The pati t en b ir ngs...a sh t ee of paper – c

for high blood pressure.... There is a [computerized

reminder reminder for high blood pressure pressure, but I guess this i

make sure we see that the patient has high blood 

case we don't see it in the computer.”

• Some electronic processes may be insufficient in te

signal to noise ratio (i.e., ability to alert clinicians r

consistently)
Longitudinal Data Process

• Task requires processing multiple data points acros

• Example: Use of a paper notebook system ‐ “I add 

ftt oo no es – anytime the [i t ti l nternational normali d ze 

too high, greater than 8.0. The primary care provid

think the INR was too high only this one time but I 

data in my notebook to show that it was too high t

times.”
Discussion

• Paper Use with the Electronic Health Record: An

Important Supplement or Negative Circumventio

• Paper processes are not necessarily inefficient o

to corresponding computer processes.

• “Paper often ser es v as a necessar necessary, sometimes sometimes s 

cognitive memory aid (Campbell et al., 2006).”

• Some paper‐based workarounds workarounds may increase increase th

opportunity for losing clinical information.

• Workaround strategies may increase efficiency b

new potential paths to medical error (Patterson 

2006)
Discussion / Conclusion

 9 categories that represent distinct reasons why 

continues to be used with the EHR

 P li o cy / d i es gn i li i mp cation: assume there will alw

paper;

 “Watch where people walk and put the sidewalk sidewalk 

 Paper workarounds: One source of variation in 

among primary care clinicians clinicians.

 Physician: “I don’t think it’s [charting in CPRS du

patient encounter] conducive to having a good

conversation. It also gives [poor] body language

were typing your notes [from this interview] righ

would say ‘Are you listening to me?’ ”would say, Are you listening to me?
Understanding variations in CPRS use 

primary care cli i i n c ans

1. How does the presence of a computer 

exam‐room i t mpac communi ti ca on b 

e 

patients and clinicians?

2. What are the barriers and facilitators 

room computing?

3. What accounts for individual and

organizational organizational difference difference in rates of e

room computing?
Understanding variations in CPRS use 

primary care clinicians

• S i ett ng: Three VA outpatient cent

Indianap , olis Memp , his and Char

S.C.

• P li opu ation:

– Primary Primary care clinicians clinicians at the clinic

clinic

– Regularly scheduled patients

• Sample: convenience sample of P

and patients
Methods: Phase 1

Location: Clinicians’ regular exam

‐rooms

Design: Video, and rapid ethnography u

observation, pre

‐

, during and po

P i it f Ph i i ti t 

encounters

Physician-patient 

encounters 

Pre-visit use

of 

CPRS 

Analyses: Qualitative analyses of Videotap

ethnographic field notes, and op

interviews
Video Coding

• Preliminary Coding

___________________________________

– Review of tapes by entire research team 

develop initial themes.

• Major Coding Categories (From Fran

al, 2005)

– Visit organization

– Interpersonal skills

– Technical mastery skills– Spatial organization

Frankel R, Altschuler A, George S, et al. Effects of exam‐room computing on clinic

communication: a longitudinal qualitative study. J Gen Intern Med. 2005;20(8):67
Thematic Analysis of Ethnograph

Interview Data

__________________________________

• Coders independently review field not

interview data underlining portions of 

that seem significant

• Assign provisional category category names

• Meet to reconcile provisional categorie

• Once established, agreed upon catego

to code the entire corpus

• Categories are linked together logically 

themes
Baseline Visit Organization Sk

Without a computer, not creating an agenda ca

vis ti

• Inefficient• Disorganized• Run over schdl e u eExam room computers will “amplify” this effe
Interpersonal Skills

Clinicians with good interpersonal skills

• Encourage patient input• Listen to patients’ concerns

• Maintain eye contact

• Chart intermittently or not at all during v
Technical Skills

Inability to successfully navigate program leads to

• Inability to access data consistently

• Wastes of time

• Frustration for clinicians and patients
Spatial Organization of the Visit

Phase 2: Understanding Organiz

Variation

• Semi structured interviews with hospit

leaders to understand understand what organizatio

organizatio

factors may influence the use of comp

the point of care.

• Interviews will be subjected to themat

qualitative analysis
Summary

• Variations in computer use at the point of care 

potential potential to increase increase or decrease decrease the quality quality of patient communication which in turn has been 

processes and outcomes of care

• Individual differences in in skills and attitudes a

differences in organizational approach may acc

large variations in use of exam room computin

• More research is needed to understand the po

impact of IT innovations on the clinician‐patien

relationship

• Guidelines and training programs could help cl

use the new technology more effectively
Rapid Assessment Process Process (R

Joan Ash, PhD et al., AMIA 2008:• “Rapid ethnography”• Traditional ethnography takes time

– researchers must d l eve op cult l ura competence a

knowledge and develop rapport and trust

• Rapid methods use several techniques to ex

this process:

– data are collected and analyzed by teams;– insiders insiders who know the culture culture are included included as te

members;

– the focus is narrow and problem‐oriented

Ash JS, Sittig DF, McMullen CK, et al. A rapid assessment process for clinical informatics 

Proc AMIA 2008:26‐30.
Concluding Remarks

• Like any new technology, exam room comp

have the potential to add to or detract from p yh sician’s efficiency and effectiveness of pand the patient’s experience of care

• Little is currently currently known about how this tec

tec

is actually used by PCPs in the real time run

organization of visits

• A human factors approach coupled with qu

descriptive descriptive methods methods is useful for addressin

addressin

in knowledge and developing solutions tha

computer computer use on both sides of the stethos

stethos
Thank you for your time a

attention !

Richard M. Frankel, PhD

E il ma : rf k l@i i d frankel@iupui.edu

Jason J. Saleem, PhD

Email: Jason.Saleem@ g va. ov