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Some Methods For Improving EMR Alerts

Posted on June 25, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new study appearing in the Journal of the American Medical Informatics Association has made some points that may turn out to be helpful in designing those pesky but helpful alerts for clinicians.

Making alerts useful and appropriate is no small matter. As we reported on a couple of years ago, even then EMR alert fatigue has become a major source of possible medical errors. In fact, a Pediatrics study published around that time found that clinicians were ignoring or overriding many alerts in an effort to stay focused.

Despite warnings from researchers and important industry voices like The Joint Commission, little has changed since then. But the issue can’t be ignored forever, as it’s a car crash waiting to happen.

The JAMIA study may offer some help, however. While it focuses on making drug-drug interaction warnings more usable, the principles it offers can serve as a model for designing other alerts as well.

For what it’s worth, the strategies I’m about to present came from a DDI Clinical Decision Support conference attended by experts from ONC, health IT vendors, academia and healthcare organizations.

While the experts offered several recommendations applying specifically to DDI alerts, their suggestions for presenting such alerts seem to apply to a wide range of notifications available across virtually all EMRs. These suggestions include:

  • Consistent use of color and visual cues: Like road signs, alerts should come in a limited and predictable variety of colors and styles, and use only color and symbols for which the meaning is clear to all clinicians.
  • Consistent use of terminology and brevity: Alerts should be consistently phrased and use the same terms across platforms. They should also be presented concisely, with minimal text, allowing for larger font sizes to improve readability.
  • Avoid interruptions wherever possible:  Rather than freezing clinician workflow over actions already taken, save interruptive alerts that require action to proceed for the most serious situation. The system should proactively guide decisions to safer alernatives, taking away the need for interruption.

The research also offers input on where and when to display alerts.

Where to display alert information:  The most critical information should be displayed on the alert’s top-level screen, with links to evidence — rather than long text — to back up the alert justification.

When to display alerts: The group concluded that alerts should be displayed at the point when a decision is being made, rather than jumping on the physician later.

The paper offers a great deal of additional information, and if you’re at all involved in addressing alerting issues or designing the alerts I strongly suggest you review the entire paper.

But even the excerpts above offer a lot to consider. If most alerts met these usability and presentation standards, they might offer more value to clinicians and greater safety to patients.

Simpler EMRs Lower Physician Stress

Posted on September 23, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

When it comes to EMRs, simpler may be better, according to a new study. 

Researchers have concluded that doctors who use EMRs with a moderate number of functions are more stressed out and have a lower level of job satisfaction than those who use EMRs with fewer functions.

The study also suggested that doctors who used highly functioning EMRs are especially challenged providing care if they feel the time allowed to do so isn’t adequate.

The study, which was reported in Healthcare Informatics magazine, originally appeared in the Journal of the American Medical Informatics Association. In the study, researchers examined variables including doctor-reported stress, burnout, satisfaction and intent to leave the practice, then used these variables to compare decisions before and after EMR systems were implemented.

To gauge how physicians react to EMR features, the study authors looked at 379 primary care physicians, along with 92 managers at 92 clinics from New York City and the upper Midwest.

The physicians and managers were participating in the Minimizing Error, Maximizing Outcome study, a 2001 – 2005 study assessing relationships between the structure and culture of the primary care workplace, physician stress and burnout, and the quality of care experienced by their patients, Healthcare Informatics reported.

The researchers actually found the job stress went down slightly for physicians using sophisticated EMR system compared to physicians with moderately complex EMRs. However, time pressure during examinations was more highly associated with adverse physician outcomes in the high EMR function group, the study authors wrote.

It’s worth remembering, however, that EMR complexity isn’t the only factor which determines how comfortable physicians are with their system.

Ultimately, seeing to it that doctors are comfortable with EMR features and functions before they’re installed and set in stone is the best way to see to their satisfaction, according to health IT expert Mark Olschesky.

Getting Personal with EMRs and Women’s Health

Posted on October 18, 2012 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

It’s that time of year again. Like my mother, I’ve taken to scheduling any sort of annual event around the time of my birthday. So, now my birthday cake is accompanied by a trip to get my emissions done, a jaunt to the tag office, and a visit to my primary care doctor for an annual physical and any other female-related health services I might need. (Timely, considering that October is also Breast Cancer Awareness Month.)

I tend not to schedule my well visits months in advance, and so was a bit apprehensive earlier in the week as I dialed in to get an appointment. I’ve read quite a few patient horror stories lately of appointments not being available for months due to lack of staff. Thankfully, this was not my experience. I was able to pick the date and time of my choosing, with the only insurance-related caveat being that I had to wait until one day after the date of my exam in 2011.

When I was at the doctor’s office last year, they were in the process of launching a patient portal. Digging around on their website while speaking with their receptionist, I noticed the portal is indeed available. The patient-centric portal offers online bill pay, appointment scheduling and pre-registration services and a personal health record. I’ll be interested to see if they mention its availability when I am seen in a few weeks. I’ll definitely ask who was involved with the implementation, and if they’re looking to Stage 2 Meaningful Use quotas when it comes to electronic patient engagement.

But enough about me. The reason I bring all this up is because the Journal of the American Medical Informatics Association recently made available research on “The effect of electronic medical record system sophistication on preventive healthcare for women.” A quick look at the abstract relates that 29.23% of providers (culled from those in the National Ambulatory Medical Care Survey from 2007-08) had no EMR system, 49.43% had minimal EMRs, 15.97% had basic EMRS, and 5.46% had fully functional EMRs.

“For breast examinations, pelvic examinations, pap tests, Chlamydia tests, cholesterol tests, mammograms, and bone mineral density tests, an EMR system increased the number of these tests and examinations,” according to the abstract. “Furthermore, the level of sophistication increased the number of breast examinations and pap, Chlamydia, cholesterol and BMD tests.”

The JAMIA’s point being that “the use of advanced EMR systems in obstetrics and gynecology was limited. Given the positive results of this study, specialists in women’s health should consider investing in more sophisticated systems.”

I’m going to play devil’s advocate here for a minute.

First of all, the fact that not even 5.5% of providers surveyed had a fully functional EMR is dismaying, but perhaps I don’t understand the underlying financial reasons for their lack of adoption. And the fact that the survey was taken more than four years ago could play a part. It would seem to me that there would be much to gain clinically and financially in having a fully function EMR especially in obstetrics, where women are often seen at a number of facilities throughout their pregnancies.

And finally, I have to take issue with the “positive results” the JAMIA concludes the study to have had. To me, “positive” connotes “successful,” so I wonder if there’s a hidden conflict of interest here. Increased sophistication of EMR systems would seem to equal more tests, according to the study, but no mention is made of if those tests lead to better outcomes (a win for patients) or higher reimbursements (a win for providers). I know we walk a fine line when talking about EMRs, tests and money, and that it often ends up being a chicken-and-egg situation, but it’s still a debate that needs to be had, especially in the area of women’s health.

When Physicians Own Practice, EMR Implementation Feels Tougher

Posted on January 30, 2012 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Here’s an EMR adoption study which interested me largely because it runs counter to what I would have predicted.  The study, which surveyed physicians pre- and post- EMR implementation, found that doctors who owned a stake in their practice found their rollout to be tougher than physicians who didn’t have a stake.

I don’t know about you, but I would have assumed that the folks with more control — the owners — would have found it easier than those who have to adapt to the decisions others make.  But it seems that physician-owners simply feel the pain of change more acutely.

To conduct the study, which was published last week in the Journal of the American Medical Informatics Association,  researchers surveyed 156 physicians working with the Massachusetts eHealth Collaborative.  The surveys included a pre-implementation questionnaire  in 2005 and a post-implementation questionnaire in 2009.

Thirty-five percent of doctors who responded reported that implementation was very difficult, 54 percent said it was somewhat difficult and 12 percent not difficult. Those numbers square pretty well with what I’ve seen elsewhere. The twist here was that 38 percent of physicians with full or partial ownership stakes in their practices voted “very difficult,” versus 27 percent of non-owners. That surprised me. After all, aren’t most of the complaints coming from doctors who try to use the new systems?

According to Marshall Fleurant, MD, one of the study’s authors, the owners “probably experienced more underlying challenges associated with EHR implementation and workflow transformation” given their broader operational responsibilities.

While this study is interesting, it’s hardly the last word. Teasing out just which factors predict how doctors will react to EMR implementation, much less what it takes to support them, is still a new science.  But it never hurts to bear in mind that physicians making critical management decisions get support, too.