1. Welcome to GRAND ROUNDS “Our EHR -- Hope and Hazards for Patient Care” Thursday, November 04, 2010 Ben-Tzion Karsh, PhD Jim Porter, MD Robert Gilbert, MD

2. Objectives: Attendees will be able to: – Describe the human factors implications of EHR use with attention to potential error and fatigue problems – Describe methods to maximize the utility EHRs in the hospital and clinic – Improve patient care through more effective EHR use

3. EHR’s – The Good, the Bad and The Ugly Is this a good idea?

4. Does the EHR help us – and our patients?

5. American Airlines: 1929 www.acepilots.com/pioneer/airscan0031.jpg There was a lot of work to be done on the concepts, the technology, the implementation and the training!

6. What we don’t know: Do EHRs improve patient care? Do EHRs reduce medical errors? – What kinds of errors are more or less likely? Do EHRs increase or decrease efficiency? What are the hazards associated with EHR use? Given existing EHRs, how can we best use them to improve patient care – and our own professional lives

7. And, now for all the answers:

8. EHRs A Human Factors Engineering Perspective Ben-Tzion (Bentzi) Karsh, PhD Associate Professor Industrial and Systems Engineering Family Medicine, Biomedical Engineering, Population Health Sciences Systems Engineering Initiative for Patient Safety University of Wisconsin-Madison

9. Acknowledgements / Conflicts No conflicts, no mention of drugs Funded by – AHRQ R18 HS017899 (PI-Karsh) – AHRQ P20 HS017115 (PI-Karsh) – AHRQ HHSA290200810036C (PIs Karsh, Carayon) – NIH R01 LM008923 (PI-Karsh) – Robert Woods Johnson Foundation (PIs Karsh, Carayon)

10. 10 Take Away Messages… Designing any information technology, to meet user needs, requires careful study not just of the users, but the users’ work The nature of the work for which we are designing health IT imparts affordances, constraints, and requirements for the design of the health IT. We need to understand these for successful design. The users, the technology, and their context of work together represent the cognitive system we seek to design. That is, we need to think of jointly designing these to work together. Installing technology and requiring the user to adapt to its limitation is the wrong way.

11. Main Take Away Message THE ROAD TO PATIENT SAFETY AND HIGH QUALITY PATIENT CARE RUNS THROUGH THE PERFORMANCE OF CLINICAL AND ANCILLARY STAFF So if technology is bad, workflows don’t work, or the physical space doesn’t work, staff performance will be bad. If staff performance is bad, patients suffer 11

12. What is human factors engineering? SCIENCE: Discovers and applies information about human behavior, abilities, limitations and other characteristics to the design of tools, machines, systems, tasks, jobs, and environments for productive, safe, comfortable and effective human use PRACTICE: Designing the fit between people and products, equipment, facilities, procedures and environments

13. What is human factors engineering? SCIENCE. Considered by many as the basic science of human performance, thus the basic science of safety, efficiency, quality PRACTICE. Evidence-based design for supporting people’s physical and cognitive work

14. A few HFE topics of study Usability Mental workload Situation awareness Human-automation interaction Alerts Lifting Training Teamwork and team training Information processing Naturalistic decision making Handoffs Interruptions / distractions Violations Human error Safety

15. Employers of human factors and ergonomics professionals Dept. of Defense NASA Medical device companies Software companies Insurance companies Manufacturing companies Process industries Agricultural companies Financial companies Health systems

16. Who was looking for HFE professionals recently? Kodak Apple US Army Research Institute Sony Ericsson Pitney Bowes Siemens Medical Lockheed Martin Whirlpool Liberty Mutual State Farm Xerox FAA

17. My world view “Throughout human history, significant innovations have always been associated with new perils. This is as much the case for fire, the wheel, aviation and nuclear power as it is for HIT. Health IT affords real opportunities for improving quality and safety. However, at the same time, it creates substantial challenges, especially during everyday clinical work.” Karsh, B., Weinger, M., Abbott, P., Wears, R. (2010). Health information technology: fallacies and sober realities. JAMIA, 17, 617-623. 17

18. Nature of technology Technology does not simply replace human activity; technology changes human activity in planned and unplanned ways EHRs do not simply replace paper. They fundamentally change clinical work. 18

19. Human factors survey response analysis Positive – Improved access “Access to charts anywhere/anytime” – Efficiencies in ordering “Electronic ordersets”

20. Negatives Signal to noise ratio problems. – “Lack of standardization of the notes. Sometimes the notes say absolutely nothing at all – just blown in data without impression” Hidden data – “Menus and sub menus and toolbars and sub toolbars with excessive redundancy that creates confusion and clutter.” Misfit with workflow – “Physician work flow has to adapt to what EPIC is willing to provide, rather than EPIC figuring out how to adapt to physician workflow.” Lack of training – “Physician education is key-we need to know what smart sets are available, what order sets are available, etc.” and “… This is certainly not something I was taught in my training for EHR.” Move toward asynchronous communication – “I think my assistant and I talk much less about how to treat patients and more about how to accomplish certain tasks in EPIC.” and “My concern is that EHR's give the impression that you don't need to communicate some things personally to other doctors and nurses. It can have the effect of decreasing important clinical issues personally.”

21. Quick thoughts about why EHRs do not entirely support the work of clinicians

22. For health IT, a major focus is on the display Wickens, C. D., Lee, J. D., Liu, Y., & Becker, S. E. G. (2004). An Introduction to Human Factors Engineering (2nd ed.). Prentice Hall. Wickens et al. 2004

23. Principle Any information, whether on paper or electronic, affects your cognitive performance (treatment and diagnosis, problem framing and solving…), whether you realize it or not. Poorly organized information taxes your attentional resources – that is not just annoying, it is dangerous.

24. Principle If a user of a system needs to hold information in memory while scrolling or toggling between screens or tabs or if you see users writing down information as they traverse multiple screens, it means that the system is not supporting their cognitive work Providing a user with only a “key-hole” view to a vast store of information effectively obscures your view of what is behind the door.

25. Principle Decision support should be less about alerts and more about providing you with the proper informational context to support your ever changing needs – Why is it that labs and medications are under different tabs? Don’t you need to see the medications to properly interpret labs? – Why can’t you see the diagnostic data on the screen you choose treatments?

26. Why does paper persist? You write down all of the related pieces of information, on one piece of paper, that you cannot see at once in the EHR This integrated view supports your cognitive work; mental gymnastics does not.

27. Workflow in healthcare What directs workflow in simple systems is the flow of materials or information that are transformed from station to station. Think a factory or fast food restaurant. In complex domains like healthcare, there are simple workflows directed by the flow of products or information, but, Many workflows in complex domains are directed not by product or information flows, and not even by prescribed tasks, but by moment-to- moment goals.

28. Principles Designing information technology to integrate into workflow or meet the needs of tasks, misses the point. Information technology for complex work must be designed differently

29. Principles When you cannot answer “what is the workflow” but designers try to design clinical IT too match your workflow you get brittle technologies – Brittle in the sense that they only apply (or apply best) when there is only one thing to do and one way to do it. They are not applicable otherwise Brittle solutions make recovery from problems much harder – E.g. written driving directions vs. a map – Poorly designed CDS? EHRs? 29

30. More on brittleness When the technologies are exposed for their brittleness, people are forced to adapt and respond (David Woods) 30

31. Principles In complex work, you need more information, not less, most of the time. But we need more research to know what information to provide. More information = information to support context and to support tasks, for any of the goals that arise

32. But won’t that lead to information overload?

33. Overload or cognitive support? http://en.wikipedia.org/wiki/File:Mission_control_center.jpg

34. 787 Dreamliner

35. Principle Complex problems require complex solutions Healthcare and patients are complex Good health IT will have to be complex Complexity ≠ Complicated Complexity requires training

36. Principles Well-designed health IT will require extensive training. We must find a way to make it normal to provide training and assess competency of health IT use. If we continue to not have time for training we are in trouble

37. THANK YOU Ben-Tzion Karsh, Ph.D. Associate Professor UW-Madison Contact Information Industrial Engineering University of Wisconsin-Madison 1513 University Avenue, Room 3218 Madison, WI 53706 Tel: 608-262-3002 Fax: 608-262-8454 E-mail: bkarsh@engr.wisc.edu www.engr.wisc.edu/mesh

38. James F. Porter, MD Department of Rheumatology Dean Clinic Medical Informatics Director - WIITTS I have nothing to disclose for this presentation

39. Communicating within an EHR Sharing knowledge from content rich software An EHR offers both opportunities and challenges in documentation and communication Communication between multiple specialist and other hospital staff in the care of complicated inpatients with multiple system disease remains challenging Excellent communication offers significant advantages in the efficient quality care of patients Does current use make for more voluminous documentation or better communication and patient care?

40. An EHR offers several potential advantages: Decision support- BPA, order sets, preference lists, chronic disease reminders. Preventative medicine- Health maintenance, drug recalls. Reporting capabilities. Coding assistance- requirements can be easily documented outside the progress note or without discreetly entering (ROS and physical exam via smart phrases/lists/text and links). Current documentation prevents achieving many of these advantages.

41. What are the components of essential communication? Why in the hospital? What is being done during the hospital stay? What factors are influencing the hospital stay? What are the discharge planning issues?

42. How are we doing? Does our current use of the EHR accurately define the clinical issues? Who is responsible for what? How is care coordinated? How do we provide others with the information they require? – Do others involved in the patient’s care understand the issues? – Are educational opportunities being taken advantage of? – Is there high provider satisfaction? – Does our documentation allow for accurate coding?

43. A case scenario,… A recent example of current EHR practices

44. 5/13/10 Admission Initial Hospital Problem List Enteritis due to radiation- noted 11/27/09 Malabsorption 11/27/09 Chills 5/13/10 Does this problem list help you know what is going on?

45. Problem list prior to admission Hypocalcaemia (nl) Hypothyroidism (stable on replacement) Hypoglobulinemia (globulin nl on CMP) Hypertension GERD CHF (history of) Asthma Colon perforation (ileostomy11/09) Diarrhea Arm pain (12/09 due PICC line infiltration) Post PICC line (placed 12/09) Peripheral neuropathy Pernicious anemia (nl) Osteoarthritis Osteoporosis Atrial fibrillation Now do you know what is going on?

46. ED Note History 77 year old female who during the last 2 days has severe chills every time she has a TPN infusion. Blood cultures drawn earlier in the day were positive and she was advised to come to the ED.

47. ED Clinical Impressions Differential includes line infection, urosepsis, pneumonia, or other acute issue. UW Records reviewed and demonstrated gram- negative rods from line culture drawn earlier today. The patient had elevated WBD, renal insufficiency, elevated glucose, low Na and Cl, UA with evidence of infection, and a chest x-ray without acute findings. Per ID the patient will be started on Cipro and Zosyn. The PICC line was removed and the tip cultured. The patient's vital signs improved with IV fluids.

48. FP Initial H&P Assessment and Plan: HS is a 77 year old female with a PMHx of uterine cancer, radiation enterocolitis, ileostomy and malabsorption now on TPN who presents with a PICC line infection with prelim ID as Gram negative rod. On admission, she was tachycardic, hypotensive, tachypenic, and with a leukocytosis consistent with SIRS, however she responded well to IVF resuscitation and is currently stable. UA also consistent with UTI. 12 separate issues commented on including: – PICC line: Blood cultures redrawn, PICC removed, cath tip sent for culture, Zosyn 3.75q6 and Ciprofloxacin 400 q12, telemetry monitoring, follow CBC in AM, f/u lactate

49. FP 5/14 Progress Note Assessment & Plan Assessment: HS is a 77 year old female admitted for an infected PICC line, meeting SIRS criteria for sepsis. Plan: (12 issues- new and old dx, symptoms, therapies and code status) – Neuro: Pain, – Resp: Asthma/COPD: Receiving outpatient dosages of Duoneb and advair – CV: Hypertension: treated outpatient with metoprolol (which she received this morning despite being hypotensive), Atrial fibrillation: receiving diltiazem, ASA and digoxin. Digoxin held this morning due to high levels. Rate controlled in the 70s-90s. Has not received coumadin because of patient refusal: requires to much laboratory monitoring. Hypotension: will recheck this morning, if she remains hypotensive, will fluid bolus. – FEN/GI: Osteotomy after bowel perforation: patient has difficulty receiving the ostomy supplies. PFS has been consulted on this topic. Also, Ms. S requested that Dr. Davis see her while in the hospital. She doesn't have any acute issues in her GI system during this admission and therefore does not require a consult at this time. There has been some discussion of takedown of her ileostomy, but I'm not sure what the timeline is for this. If Dr. Davis is able to see Ms. S and this is a possibility for her, Dr. M will be consulted as well. If it is decided that she will continue to receive TPN, discussion of receiving second PICC should be started once she is appropriately treated for her current infection and blood cultures are negative. – Diet: Ms. S that she's tolerating her diet well without complications. Will order pre-albumin today to evaluate nutritional status. Iron deficiency: currently, she is not anemic and her MCV is 82 fL Hypocalcaemia: continue outpatient dose of Calcium-Vitamin D. – Renal: Pre-renal azotemia: improved from yesterday, but still has a BUN/Cr ratio of ~30. Fluids are currently going at 150 ml/hour. Will continue to monitor. – ID: PICC infection/bacteremia: currently on iv zosyn and cipro. Awaiting final identification and sensitivities. Will tailor antibiotics based on results. Receiving lactobacillus as well. Daily blood cultures. UTI: culture results pending, has adequate coverage on current antibiotics. Will tailor antibiotics based on results – Heme: 3 g drop in Hemoglobin: possibly delusional/related to blood draws. Will repeat at 6 p.m. To evaluate. – Endo: Hypothyroidism: stable on home dose of synthroid 150 mcg. – Psych: Depression/anxiety: continue outpatient amitriptyline and prozac – Prophylaxis : Omeprazole – Code status: Full

50. 5/18/10 Consult GI Impression & Plan Ms. S is a 77 yo f, s/p ileostomy placement and previous history of radiation enteritis and small bowel resection due to obstruction. She has had chronic diarrhea preceding the ostomy placement which post surgery has worsened. She is 6 months post ileostomy. She has tried multiple medications in the past. Octreotide could be considered if she is able to get this at home. If so - we could try it as an inpt to see if it is effective. She has a difficult problem compounded by radiation changes and short bowel in addition to an ileostomy. An alternative option would be to restart her tincture of opium with close monitoring (if it can be obtained in an affordable manner).

51. 5/18 FP Progress Note Subjective: Has pain in her L wrist, feels that it is swollen. Does not recall any trauma to the area. No history of gout. Says that she takes Advil for her arthritis pain. Admits to feeling dizzy occasionally. Says she's "really all right" and is ready to go home. Ostomy output remains very high, and she is seeing whole pills come out of her ostomy. This is the issue that prevents her discharge currently is concern that this increased output will continue at home, causing rapid malnourishment. Received a call from GI attending regarding treatment for her ostomy output, he wonders if she has ever received octreotide when she was at Select or Meriter. Received tincture of opium in the past, but the cost varied from 9 to 900 dollars. She thought that it worked a bit. Assessment: HS is a 77 year old female admitted for bacteremia related to PICC line, now on oral antibiotics, which she is tolerating well. Issue preventing discharge has changed from her infection to her high-output ostomy, as she has a risk of rapidly becoming malnourished if this lack of absorption continues. She has received attention from ostomy nurse, who has recommended appropriate follow up with Dean wound clinic on Fish Hatchery Plan: Comment on 10 issues Of note, I was asked to see this patient on a later 6/28/10 admission for wrist pain. There was no mention of prior wrist issues, but the patient remembered have a prior x-ray which allowed me to find this note. She had Pseudogout.

52. GI Progress Note 5/21 EVENTS: tincture of opium started yesterday and dose increased today Exam: Stool output past 24 hours: 3400 Oral intake past 24 hours: 1455 Impression/Plan: Ms. S is a 77 yo F with h/o small bowel resection, radiation enteritis and loop ileostomy. She has very high ostomy output which is likely a result of shortened small bowel with previous radiation injury. She was started on octreotide on 5/18 with no improvement in stool output. Yesterday she was started on tincture of opium and dose increased today. So far her output remains far greater than her oral intake. She has told us that she does not want a groshong or PICC placed for IV hydration but GI physician who follows her is yet to discuss this with her. She appears to need at least some IV hydration at home and this is the goal. Will follow her ostomy output for improvement on tincture of opium. She is sleepy today and would hold off on any further increase until we are sure how she will respond to it. On Octreocitde from 5/18-22 On Tinture of Opium from 5/20-d/c on 5/26

53. 5/22/10 FP Progress Note Active Inpatient problem list, Assessment and Plan: 1. PICC line bacteremia - initial cultures with K. Pneumonia; subsequent cultures negative. On TMP-SMX since 5/16, afebrile. Day 10/14 overall of Abx. 2. Depression & anxiety - continue amitriptyline, fluoxetine 3. Wrist pain - uric acid still pending canceled on 5/19, ESR 73. Seen by ortho, felt to be tendinitis rather than inflammatory – arthropathy. – continue oxycodone for pain 4. Bibasilar atelectasis - continue incentive spirometry 5. Chronic atrial fibrillation, HTN - metoprolol tartrate pushed back up to home dose (25 mg PO BID) for higher rates yesterday. On diltiazem, ASA, digoxin. Rate controlled for the most part, BP normal range. Pt not interested in warfarin, too much lab monitoring required. 6. Acute kidney injury - Cr stable at 1.1, BUN improved with IV hydration. Baseline Cr 0.7. Likely pre-renal, related to poor gut fluid absorption & large volume ostomy output. - continue IV hydration with D5 1/2 isotonic saline 7. Chronic rapid gut transit / malabsorption - details documented elsewhere in the record. Currently on TID subQ Octreocitde, tincture of opium at 3 ml TID. Care coordination meeting planned for Monday - need to come up with sustainable outpatient plan to keep her hydrated. - hold tincture of opium (see below), continue Octreocitde at current dose - check B12, folate - will need instruction in better hygiene with ostomy care 8. GERD - continue omeprazole 9. Hypothyroidism - continue home levothyroxine. 10. Altered mental status - her conversation has seemed tangential from admission, but she's clearly confused the last 2 days and is having a hard time communicating. Have to strongly suspect that tincture of opium is contributing, especially knowing that she'd had cognitive problems with it in the past (albeit at higher doses). Wonder whether there is some dementia present, be it chronic or more subacute, possibly related to nutritional deficiencies. - OT & PT - hold tincture of opium for now (on chronic long acting narcotics for pain not otherwise defined) 11. Glaucoma - complaining of eye pain; ophthalmology consult ordered 12. Leukocytosis - unclear etiology. Negative blood cultures, afebrile. UA pending. 13 Normocytic anemia - Hgb down to 12.1 from 12.6, no obvious source of blood loss. Fe deficiency, chronic disease, nutrient deficiencies all potentially contributory. B12 & folate pending, continue ferrous sulfate 325 mg daily Full code.

54. Admission Assessment and Plan Does this promote good communication? – Do others involved in the patient’s care understand the issues? – Is discharge planning being efficiently done? – Are educational opportunities being taken advantage of? – Is there high provider satisfaction? – Is our coding compliant with regulations?

55. Is there a better way to communicate within Epic? Problem list – Available to all care givers – Identifies were the focus should be – Source for identifying diagnosis for decision support – Allows for a d/c problem list (similar to med reconciliation) Progress note – Identify daily changes and the plan for active hospital problems – Clarify discharge planning issues

57. (From the hospital problem list hyperlink) (***)

58. I have Nothing to Disclose for this Presentation Robert D. Gilbert, MD Department of Internal Medicine - Dean Clinic Medical Informatics Director - WIITTS

59. COMMUNICATION EXPECTATIONS Electronic Record / Person Passive entry / Active message Use Now / Future Utility Sender expects / Receiver performs Statement / Conversation

60. Our Planning Team: John W. Beasley, M.D., UW Department of Family Medicine, Planning Team Chair Robert D. Gilbert, M.D., St. Mary’s Hospital Medical Center and Dean Clinic Ben-Tzion (“Bentzie”) Karsh, Ph.D., UW Department of Industrial and Systems Engineering James F. Porter, M.D., St. Mary’s Hospital Medical Center and Dean Clinic All practitioners who assisted us with the pre-assessment survey

61. Questions & Comments Welcome Today’s presentation and handouts will be placed on both Dean & St. Mary’s Intranet sites Next Grand Rounds: Thursday, February 3, 2011 Clostridium Difficile & Central Venous Line Disease