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Item Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation(Oxford University Press, 2014-10) Russ, Alissa L.; Zillich, Alan J.; Melton, Brittany L.; Russell, Scott A.; Chen, Siying; Spina, Jeffrey R.; Weiner, Michael; Johnson, Elizabette G.; Daggy, Joanne K.; McAnas, M. Sue; Hawsey, Jason M.; Puleo, Anthony G.; Doebbeling, Bradley N.; Saleem, Jason J.; Medicine Faculty Volunteers, IU School of MedicineOBJECTIVE: To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. MATERIALS AND METHODS: We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. RESULTS: Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024). DISCUSSION: Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. CONCLUSIONS: This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes.Item The state of the art in clinical knowledge management: An inventory of tools and techniques(2010-01) Sittig, Dean F.; Wright, Adam; Simonaitis, Linas; Carpenter, James D.; Allen, George O.; Doebbeling, Bradley N.; Sirajuddin, Anwar Mohammad; Ash, Joan S.; Middleton, BlackfordPurpose To explore the need for, and use of, high-quality, collaborative, clinical knowledge management (CKM) tools and techniques to manage clinical decision support (CDS) content. Methods In order to better understand the current state of the art in CKM, we developed a survey of potential CKM tools and techniques. We conducted an exploratory study by querying a convenience sample of respondents about their use of specific practices in CKM. Results The following tools and techniques should be priorities in organizations interested in developing successful computer-based provider order entry (CPOE) and CDS implementations: (1) a multidisciplinary team responsible for creating and maintaining the clinical content; (2) an external organizational repository of clinical content with web-based viewer that allows anyone in the organization to review it; (3) an online, collaborative, interactive, Internet-based tool to facilitate content development; (4) an enterprise-wide tool to maintain the controlled clinical terminology concepts. Even organizations that have been successfully using computer-based provider order entry with advanced clinical decision support features for well over 15 years are not using all of the CKM tools or practices that we identified. Conclusions If we are to further stimulate progress in the area of clinical decision support, we must continue to develop and refine our understanding and use of advanced CKM capabilities.Item The effect of provider- and workflow-focused strategies for guideline implementation on provider acceptance(2009-10) Flanagan, Mindy E.; Ramanujam, Rangaraj; Doebbeling, Bradley N.Background The effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs. Methods Surveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2,438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models. Results For all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used. Conclusion Provider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.Item VA-INPC: Linking Department of Veterans Affairs (VA) and Indiana Network for Patient Care (INPC) data to assess surveillance testing among veterans with colorectal cancer(2010-11) Haggstrom, David A.; Rosenman, Marc; Myers, Laura J.; Teal, Evgenia; Doebbeling, Bradley N.The goal of this project was to provide empiric evidence about the benefit to US veterans and the VA of capturing data from a citywide clinical informatics network (INPC) to assess care received outside the VA. We identified 468 veterans diagnosed with colorectal cancer from 2000–2007 in the Indianapolis VA cancer registry. Electronic VA healthcare data were linked with electronic health records from the regional health information organization (RHIO) INPC; 341 matches were found. Both the VA and INPC systems were queried regarding receipt of surveillance tests. The proportion with additional data from INPC varied by test: colonoscopy (3%), CT scan/abdomen (13%), CT scan/chest (79%), carcinoembryonic antigen test (8%), and other laboratory tests (25%–53%). An incremental benefit of linking VA and INPC data was present and may increase when expanded beyond patients with a single condition. New, important information about care outside the VA is obtained through RHIO data linkage.Item Optimizing Perioperative Decision Making: Improved Information for Clinical Workflow Planning(2012-11) Doebbeling, Bradley N.; Burton, Matthew M.; Wiebke, Eric A.; Miller, Spencer; Baxter, Laurence; Miller, Donald; Alvarez, Jorge; Pekny, JosephPerioperative care is complex and involves multiple interconnected subsystems. Delayed starts, prolonged cases and overtime are common. Surgical procedures account for 40–70% of hospital revenues and 30–40% of total costs. Most planning and scheduling in healthcare is done without modern planning tools, which have potential for improving access by assisting in operations planning support. We identified key planning scenarios of interest to perioperative leaders, in order to examine the feasibility of applying combinatorial optimization software solving some of those planning issues in the operative setting. Perioperative leaders desire a broad range of tools for planning and assessing alternate solutions. Our modeled solutions generated feasible solutions that varied as expected, based on resource and policy assumptions and found better utilization of scarce resources. Combinatorial optimization modeling can effectively evaluate alternatives to support key decisions for planning clinical workflow and improving care efficiency and satisfaction.Item Redesign of a computerized clinical reminder for colorectal cancer screening: a human-computer interaction evaluation(2011-11) Saleem, Jason J.; Haggstrom, David A.; Militello, Laura G.; Flanagan, Mindy; Kiess, Chris L.; Arbuckle, Nicole; Doebbeling, Bradley N.Background Based on barriers to the use of computerized clinical decision support (CDS) learned in an earlier field study, we prototyped design enhancements to the Veterans Health Administration's (VHA's) colorectal cancer (CRC) screening clinical reminder to compare against the VHA's current CRC reminder. Methods In a controlled simulation experiment, 12 primary care providers (PCPs) used prototypes of the current and redesigned CRC screening reminder in a within-subject comparison. Quantitative measurements were based on a usability survey, workload assessment instrument, and workflow integration survey. We also collected qualitative data on both designs. Results Design enhancements to the VHA's existing CRC screening clinical reminder positively impacted aspects of usability and workflow integration but not workload. The qualitative analysis revealed broad support across participants for the design enhancements with specific suggestions for improving the reminder further. Conclusions This study demonstrates the value of a human-computer interaction evaluation in informing the redesign of information tools to foster uptake, integration into workflow, and use in clinical practice.Item Patient-Centered Appointment Scheduling Using Agent-Based Simulation(2014-11) Turkcan, Ayten; Toscos, Tammy; Doebbeling, Bradley N.; Department of BioHealth Informatics, School of Informatics and ComputingEnhanced access and continuity are key components of patient-centered care. Existing studies show that several interventions such as providing same day appointments, walk-in services, after-hours care, and group appointments, have been used to redesign the healthcare systems for improved access to primary care. However, an intervention focusing on a single component of care delivery (i.e. improving access to acute care) might have a negative impact other components of the system (i.e. reduced continuity of care for chronic patients). Therefore, primary care clinics should consider implementing multiple interventions tailored for their patient population needs. We collected rapid ethnography and observations to better understand clinic workflow and key constraints. We then developed an agent-based simulation model that includes all access modalities (appointments, walk-ins, and after-hours access), incorporate resources and key constraints and determine the best appointment scheduling method that improves access and continuity of care. This paper demonstrates the value of simulation models to test a variety of alternative strategies to improve access to care through scheduling.Item Provider Perceptions of Colorectal Cancer Screening Clinical Decision Support at Three Benchmark Institutions(2009-11) Saleem, Jason J.; Militello, Laura G.; Arbuckle, Nicole; Flanagan, Mindy; Haggstrom, David A.; Linder, Jeffrey A.; Doebbeling, Bradley N.Implementation of computerized clinical decision support (CDS), and its integration into workflow has not reached its potential. To better understand the use of CDS for colorectal cancer (CRC) screening at benchmark institutions for health information technology (HIT), we conducted direct observation, including opportunistic interviews of primary care providers, as well as key informant interviews and focus groups, to document current challenges to CRC screening and follow-up at clinics affiliated with the Veterans Heath Administration, Regenstrief Institute, and Partners HealthCare System. Analysis revealed six common barriers across institutions from the primary care providers’ perspective: receiving and documenting “outside” exam results, inaccuracy of the CDS, compliance issues, poor usability, lack of coordination between primary care and gastroenterology, and the need to attend to more urgent patient issues. Strategies should be developed to enhance current HIT to address these challenges and better support primary care providers and staff.Item Multihospital Infection Prevention Collaborative: Informatics Challenges and Strategies to Prevent MRSA(2013-11) Doebbeling, Bradley N.; Flanagan, Mindy E.; Nall, Glenna; Hoke, Shawn; Rosenman, Marc; Kho, AbelWe formed a collaborative to spread effective MRSA prevention strategies. We conducted a two-phase, multisite, quasi-experimental study of seven hospital systems (11 hospitals) in IN, MT, ME and Ontario, Canada over six years. Patients with prior MRSA were identified at admission using regional health information exchange data. We developed a system to return an alert message indicating a prior history of MRSA, directed to infection preventionists and admissions. Alerts indicated the prior anatomic site, and the originating institution. The combined approach of training and coaching, implementation of MRSA registries, notifying hospitals on admission of previously infected or colonized patients, and change strategies was effective in reducing MRSA infections over 80%. Further research and development of electronic surveillance tools is needed to better integrate the varied data source and support preventing MRSA infections. Our study supports the importance of hospitals collaborating to share data and implement effective strategies to prevent MRSA.Item Persuasive health educational materials for colorectal cancer screening(2014-09) Militello, Laura G.; Borders, Morgan R.; Arbuckle, Nicole B.; Flanagan, Mindy E.; Hall, Nathan P.; Saleem, Jason J.; Doebbeling, Bradley N.This paper describes an effort to design and evaluate persuasive educational materials for colorectal cancer (CRC) screening. Although CRC screening is highly effective, screening rates in the US remain low. Educational materials represent one strategy for educating patients about screening options and increasing openness to screening. We developed a one-page brochure, leveraging factual information from the Centers for Disease Control and Prevention (CDC) and national guidelines, and strategies for persuasion from the human factors and behavioral economics literatures. We evaluated the resulting brochure with adults over the age of 50. Findings suggest that the educational brochure increases knowledge of CRC and screening options, and increases openness to screening. Furthermore, no significant difference was found between the new one-page brochure and an existing multi-page Screen for Life brochure recommended by the CDC. We interpret these findings as indication that the more practical and potentially less intimidating one-page brochure is as effective as the existing multi-page Screen for Life brochure.