Qua ys Qualitat ve a a s o ive a

n

alys

is o

f VA

personnel experiences with personnel experiences with electronic medical record electronic medical record 

Laura Bonner, PhD August 21, 2012 August 21, 2012 VA Puget Sound VISN 20 GRECC HSR&D Northwest COE 
Co-Authors Authors 

y Carol Simons Carol Simons y Louise Parker, PhD y Elizabeth Yano, PhD y JoAnn Kirchner MD JoAnn Kirchner, MD 
OverviewOverview OverviewOverview 

y Provide context ofVA EHR Provide context ofVA EHR y Increase understanding of VA pe

evaluation of advantages, disadvaand barriers associated with VA 

y Discuss potential solutions 

BackgroundBackground BackgroundBackground 

y Emphasis on EHR potential to Emphasis on EHR potential to 

◦ Improve quality of care ◦ Improve cost-effectiveness ◦ Facilitate communication ◦ Empower patients 

y Concerns Concerns 

◦ Over-reliance on templates ◦ Time management ◦ Loss of interp ersonal relationships◦ Unintended consequences 
Create pollCreate poll Create pollCreate poll 

y Have you/do you use CPRS? Have you/do you use CPRS? 

◦ Yes ◦ No 
VA EHR 

y Implemented beginning in mid Implemented beginning in mid-1y Near-universal today y Provides 

◦ Documentation Documentation ◦ Decision support ◦ Support for billing, scheduling and 
Create pollCreate poll Create pollCreate poll 

y What is your favorite feature of 

What is your favorite feature of 

◦ Tracking patient progress over tim◦ Exchanging information with other ◦ Placing orders and consults◦ Other 
Context Context 

y TIDES: Collaborative care for de

TIDES: Collaborative care for dein 10 VAMCs/CBOCs in 3 VISNs 

y COVES (Cost and Value of Evide

based Solutions for dep ) ression) evaluation of TIDES implementa
ParticipantsParticipants ParticipantsParticipants 

y Front-line clinicians clinicians, clinical clinical man

man

other stakeholders (n=72; 67 in phone) 

y Phy , , p y g 

sicians, nurses, psychologists

administrators 

y R lt t b k d b 

Results not broken down by partype 
Methodology Methodology 

y Semi

-structured interviews structured interviews 

y Interviewers: Psychiatrist, psych

social worker, 2 health services researchers 

y VA patients were interviewed b

menti d i f ti d 

tioned i

n

formatics and were 

included in this paper 
Example interview questi

Example interview questi

y How similar/dissimilar do you b

How similar/dissimilar do you bdepression is to other chronic isuch as diabetes and heart disea

y Can 

y ou tell me what y 

our facili

part of the TIDES program? 

y Did h ti 

Did you ever have a suggestion 

to improve the program or som

you thought might not have beeworkin

g

?
Qualitative analysis Qualitative analysis 

y Qualitative analysis: themes der

rea

ding interview transcripts 

y 22 to

p -level codes 

were develo

on these themes 

y Interviews analyzed as a whole Interviews analyzed as a whole y Atlas.ti used to manage the cod

process 

y Coding team: 1st 2nd 3rd y Coding team: 1 

, 2 

, 3 author 

author 

member of project team S b d 1 2 d 

y

S

u

bco

ding team:1 h st 

& 2

nd aut

hor
Coding consistency Coding consistency 

y Authors reviewed transcripts fo

Authors reviewed transcripts foconsistency 

y Conducted word searches to en

content was not missed 
Results Results 

y Results included information ab

Results included information abimplementation, quality improverole of informatics 

◦ Informatics support was a tool in T◦ Discussion of informatics was not 

about TIDES 
Results: Benefits Results: Benefits 

VA employees value the ability of the cVA employees value the ability of the cinformatics system to 

◦ speed d i ocumentation 

◦ improve communication 

◦ improve quality 
Results: Concerns Results: Concerns 

VA employees have strong concerns aVA employees have strong concerns ainformatics system 

i f i

 i 

◦ inter

fering 

with h id t

he provider-patie

relationship 

◦ consuming time that would otherw

been available for clinical tasks 
Benefits: communication Benefits: communication 

y

“[O]ur computerized record sy

computerized record sy

makes it awfully easy for the me

health, primary care to work wiother...” 
Benefits: quality of care Benefits: quality of care 

y

“[the clinical reminder] reminds us t

[the clinical reminder] reminds us t

with...people and ask... are you feelidepressed if we didn depressed... if we didn t have the rem

't have the rem

may not take the time to do that.” 

y “[Y]ou can h lt f th t 

 have a consult form th

at 

questions or builds in information ... 

f fi ld force fi

elds so you say ... h th 

ere are th

e 

criteria, here are the screening crite

pati t t th ? H d 

tient met these

?... Have you done 

assessment?... Do they have contrainH t i d thi i iti l i t ti Have you t

ried thi

s i

niti

al i

n

terventio
Barriers: time Barriers: time 

y

“CPRS is great but it takes time to u

CPRS is great, but it takes time to u

[Providers] have to see very complic

patients in 20 minutes and With evpatients in 20 minutes, and...With evand click on a computer it's less timspend with a patient They generally spend with a patient.They generally take care of the patients.” 

y “ h li k it t k t t k 

“

...

how many 

cli

c

k

s it took t

o t

a

ke c

diabetic patient...I clicked through a

remi d it' h d d ” in

ders...it'

s hun

dre

ds.” 
Barriers: impersonality Barriers: impersonality 

y

“All these checklists clerks sh

All these

...checklists

, clerks sh

doing that.... Doctors need to siand look someone in the eye...W

reall

y g ybothering 

you?”

y “I'm asking physicians...to know 

trust me simply by what they hatrust me simply by what they hamy progress notes ... and most ohave not met me personall ”y. 
' '

Concerns: misuse Concerns: misuse 

y “There have been a couple of ti

There have been a couple of ti

providers will respond back to mthey're forgetting that they're in p atient's medical record and wilwould you like me to do where ... appropriate ... appropriate ”
Concerns: context Concerns: context 

y

“We don t flunk in depression 't flunk in depressionscreening...we flunk in follow u

y “[I]f the providers are overwhel

clinical reminders

, y the

y become

somewhat numb to them ... It's system issue

”
Valued attributes and functions of the 

EHR 

Barriers and concerns EHR 

Asynchronous communication allows VA personnel to send and receive information at a time convenient for them 

Time required to comple

Support for appropriate documentation Inappropriate conversatio

medical record 

Can easily alert other providers about a patient's status Impersonality: with colleaReminders prompt providers to initiate important conversations Impersonality: with patienStructured consults and reminders provide guidance to providers about evidence-based priorities 

Systems issues: reminders process of evidence-based the complete process 

Adapted from Bonner et al. (2010) Implementation Science 5:63 
Barriers Recommended facilitators 

Concerns about time 

Emphasize efficiency, potential timexample, asynchronous communic

if notes if appropri ) ate 

1. Physical positioning of compute

Concerns about effect on relationship with patients 

disruption of eye contact 2. Emphasize positive effects on re(reminders opening up important 

Concerns about effect on relationship with colleagues Emphasize benefits of improved co

Adapted from Bonner et al. (2010) Implementation Science 5:63 
Summary Summary 

y Emphasis on EHR potential to Emphasis on EHR potential to 

◦ Improve quality of care ◦ Improve cost-effectiveness ◦ Facilitate communication ◦ Empower patients 

y Concerns Concerns 

◦ Over-reliance on templates ◦ Time management ◦ Loss of interp ersonal relationships◦ Unintended consequences 
Directions for the future Directions for the future 

y EHR will continue to be import

EHR will continue to be import

y Relationship with technology is y New issues will include appropr

of social media of social media 

y Ongoing assessment of interplay 

tech l d l l l 

hnology and 

clinical relations

recommended 
Acknowledgments Acknowledgments 

y Lisa Rubenstein MD Lisa Rubenstein, MD y Ed Chaney, PhD y Fen Liu, PhD y Mona Ritchie, MSW y Jackie Fickel, PhD y Penny White Penny White y COVES Participants y VA Q li E h R h I 

VA Quality E

n

hancement Research I

(MNT-02-209) 
ReferencesReferences ReferencesReferences 

y Bonner LM, Simons CE, Parker LE,Yano EM, Kirchn

Bonner LM, Simons CE, Parker LE,Yano EM, Kirchntake care of the patients’: Qualitative analysis of VetAdministration personnel experiences with a clinicsystem. Implementation Science 5: Implementation Science, 5:63 

y Laura.bonner@va.gov