Health Record Use Research Articles

Health Outcomes and Healthcare Efficiencies Associated with the Use of Electronic Health Records in Hospital Emergency Departments: a Systematic Review

Healthcare organisations and governments have invested heavily in electronic health records in anticipation that they will deliver improved health outcomes for consumers and efficiencies across emergency departments. Despite such investment, electronic health records designed to support emergency care have been poorly evaluated. Given the accelerated development and adoption of information technology across healthcare, it is timely that a systematic review of this evidence base is updated in order to drive improvements to design, interoperability and overall clinical utility of electronic health record systems implemented in emergency departments. To assess the impact of electronic health records on healthcare outcomes and efficiencies in the emergency department we carried out a systematic review of published studies on this topic. This is the first review to summarise the cost efficiencies associated with electronic health record use outside of just the United States of America. A systematic search was performed in three scientific databases (MEDLINE, EMcare and EMBASE), of literature published between January 2000 and September 2019. Studies were included in this review if they evaluated electronic health records or health information exchanges (and synonyms for these terms), reported patient outcome and/or healthcare efficiency benefits, were peer-reviewed and published in English. Out of 6635 articles, 23 studies met our inclusion criteria. Wide variation regarding electronic health record access in the emergency department was reported (1.46-56.6%), yet was most frequently reported as less than 20%. Seven different types of health outcomes and three different types of efficiency improvements associated with electronic health record use in the emergency department were identified. The most frequently reported findings were efficiencies, including reductions in diagnostic tests, imaging and costs. This review is the first to report moderate to significant increases in admission rates are associated with electronic health record use in the emergency department, contrasting the findings of previous reviews. Diversity in the methodology employed across the included studies emphasises the need for further research to examine the impact of electronic health record implementation and system design on the findings reported, in order to ensure return on investment for stakeholders and optimised consumer care.

Students’ perceptions on their use of an EHR: pilot questionnaire study

IntroductionMany clinical education programmes have not incorporated the use of the electronic health record (EHR) into their curriculum. It is important to incorporate technologies that will be used in real-world...

Information quality life cycle in secondary use of EHR data

The paper argues that existing research on information quality (IQ) mainly focuses on the primary use of electronic health record (EHR) data, whereas IQ in secondary use of EHR data needs further deliberation. The current view of IQ in a healthcare context is static. It assumes that once the EHR system generates the information product, individual users may act on the information based on their subjective perception of its quality. However, this view ignores the complexities of secondary use of EHR data, in which users are actively involved in (re)generating and communicating the information product. Thus, IQ does not remain static but keeps on transforming through active engagement and interpersonal communication. To contribute to this debate, we conducted a qualitative case study in a Norwegian healthcare context by employing an IQ life cycle model. In conclusion, we enhanced the existing IQ model by (1) adding interpersonal communication, (2) showing the interrelations of the IQ dimensions, and (3) integrating the mechanisms of the transformation process for IQ in secondary use of EHR data. In doing so, we unfold the dynamics of IQ in the secondary use of EHR data.

Association of Electronic Health Record Use Above Meaningful Use Thresholds With Hospital Quality and Safety Outcomes

By 2018, Medicare spent more than $30 billion to incentivize the adoption of electronic health records (EHRs), based partially on the belief that EHRs would improve health care quality and safety. In a time when most hospitals are well past minimum meaningful use (MU) requirements, examining whether EHR implementation beyond the minimum threshold is associated with increased quality and safety may guide the future focus of EHR development and incentive structures. To determine whether EHR implementation above MU performance thresholds is associated with changes in hospital patient satisfaction, efficiency, and safety. This quantile regression analysis of cross-sectional data used publicly available data sets from 2362 acute care hospitals in the United States participating in both the MU and Hospital Value-Based Purchasing (HVBP) programs from January 1 to December 31, 2016. Data were analyzed from August 1, 2019, to May 22, 2020. Seven MU program performance measures, including medication and laboratory orders placed through the EHR, online health information availability and access rates, medication reconciliation through the EHR, patient-specific educational resources, and electronic health information exchange. The HVBP outcomes included patient satisfaction survey dimensions, Medicare spending per beneficiary, and 5 types of hospital-acquired infections. Among the 2362 participating hospitals, mixed associations were found between MU measures and HVBP outcomes, all varying by outcome quantile and in some cases by interaction with EHR vendor. Computerized provider order entry (CPOE) for laboratory orders was associated with decreased ratings of every patient satisfaction outcome at middle quantiles (communication with nurses: β = -0.33 [P = .04]; communication with physicians: β = -0.50 [P < .001]; responsiveness of hospital staff: β = -0.57 [P = .03]; care transition performance: β = -0.66 [P < .001]; communication about medicines: β = -0.52 [P = .002]; cleanliness and quietness: β = -0.58 [P = .007]; discharge information: β = -0.48 [P < .001]; and overall rating: β = -0.95 [P < .001]). However, at middle quantiles, CPOE for medication orders was associated with increased ratings for communication with physicians (τ = 0.5; β = 0.54; P = .009), care transition (τ = 0.5; β = 1.24; P < .001), discharge information (τ = 0.5; β = 0.41; P = .01), and overall hospital ratings (τ = 0.5; β = 0.97; P = .02). At high quantiles, electronic health information exchange was associated with improved ratings of communication with nurses (τ = 0.9; β = 0.23; P = .03). Medication reconciliation had positive associations with increased communication with nursing at low quantiles (τ = 0.1; β = 0.60; P < .001), increased discharge information at middle quantiles (τ = 0.5; β = 0.28; P = .03), and responsiveness of hospital staff at middle (τ = 0.5; β = 0.77; P = .001) and high (τ = 0.9; β = 0.84; P = .001) quantiles. Patients accessing their health information online was not associated with any outcomes. Increased use of patient-specific educational resources identified through the EHR was associated with increased ratings of communication with physicians at high quantiles (τ = 0.9; β = 0.20; P = .02) and with decreased spending at low-spending hospitals (τ = 0.1; β = -0.40; P = .008). Increasing EHR implementation, as measured by MU criteria, was not straightforwardly associated with increased HVBP measures of patient satisfaction, spending, and safety in this study. These results call for a critical evaluation of the criteria by which EHR implementation is measured and increased attention to how different EHR products may lead to differential outcomes.

National Trends in Daily Ambulatory Electronic Health Record Use by Otolaryngologists.

Since their development in the 1970s electronic health records (EHRs) are now nearly ubiquitous. This study aims to characterize the daily interactions of otolaryngology providers with EHRs. This study was a cross-sectional review of provider efficiency profile (PEP) data, as collected by a major EHR vendor. Participating institutions had 6 months of de-identified PEP data reviewed starting January 1, 2019. PEP data is generated for providers with scheduled patients, both attendings and advanced practice providers (APPs). Time metrics are recorded when a provider is interacting with the EHR including a 5-second time-out for inactivity. Data on 269 otolaryngologists and 29 APPs from 10 institutions were evaluated. On scheduled ambulatory clinic days attendings spent 70 ± 36 (mean ± standard deviation) min interacting in the EHR versus 108 ± 46 min for APPs. Of the daily EHR time, mean time in notes, clinical review, in basket, orders, and schedule were 30.1 ± 19.4, 9.6 ± 6.1, 7.3 ± 5.8, and 5.8 ± 7.6 min, respectively. Per patient visit, median (interquartile range) time in notes, clinical review, and orders were 3.19 (2.2-4.9), 1.14 (0.63-1.8), and 0.70 (0.47-1.05) min, respectively. Mean progress note length was 4638 ± 2143 characters. Otolaryngology providers spend a meaningful portion of their clinic day interacting with the EHR. PEP data may provide means to target interventions and a metric to measure the impact of those interventions on provider EHR efficiency. 3 Laryngoscope, 131:975-981, 2021.

Implicit bias of encoded variables: frameworks for addressing structured bias in EHR-GWAS data.

The ‘discovery’ stage of genome-wide association studies required amassing large, homogeneous cohorts. In order to attain clinically useful insights, we must now consider the presentation of disease within our clinics and, by extension, within our medical records. Large-scale use of electronic health record (EHR) data can help to understand phenotypes in a scalable manner, incorporating lifelong and whole-phenome context.However, extending analyses to incorporate EHR and biobank-based analyses will require careful consideration of phenotype definition. Judgements and clinical decisions that occur ‘outside’ the system inevitably contain some degree of bias and become encoded in EHR data. Any algorithmic approach to phenotypic characterization that assumes non-biased variables will generate compounded biased conclusions. Here, we discuss and illustrate potential biases inherent within EHR analyses, how these may be compounded across time and suggest frameworks for large-scale phenotypic analysis to minimize and uncover encoded bias.

Improvement of the module for occupational diseases in the structure of occupational health record

Abstract The study is based on the National Science Program 'eHealth in Bulgaria (e-Health)', funded by the Ministry of Education and Science. Partnership Contract No. D-01-200/16.11.2018 Issue Occupational health is closely linked to public health and health system. In Bulgaria there are many software products related to the registration and reporting of occupational health. Description of the Problem It is necessary to study all the determinants of occupational health, including the risks of diseases and accidents in the occupational environment, social and individual factors. The establishment of electronic systems for registering and monitoring both the health status of each worker and the possible hazards in the work environment is associated with the introduction and use of the occupational health record of each worker. Results The methodology for improving the module for occupational diseases in the structure of the occupational health record in Bulgaria has been developed. The classifications are in compliance with the legislation in the country and the requirements of the developing Eurostat methodology for European statistics on occupational diseases are applied. The occupational health record will serve both employers and physicians working in Occupational Health Services. Lessons The occupational disease module in the structure of the occupational health record will contribute to the statistical comparability of occupational disease data at regional and national level. Not only will the registration of the harmful factors of the working environment and the diseases related to the work process, but also the introduction of timely measures to ensure good occupational and public health. Key messages Through the occupational disease module, the structure of the occupational health record introduces the possibility of taking adequate measures to ensure good occupational health. The occupational health record will serve both employers and physicians working in Occupational Health Services.

Exemplary Practices in Cardiovascular Care: Results on Clinical Quality Measures from the EvidenceNOW Southwest Cooperative.

Identifying characteristics of primary care practices that perform well on cardiovascular clinical quality measures (CQMs) may point to important practice improvement strategies. To identify practice characteristics associated with high performance on four cardiovascular disease CQMs. Longitudinal cohort study among 211 primary care practices in Colorado and New Mexico. Quarterly CQM reports were obtained from 178 (84.4%) practices. There was 100% response rate for baseline practice characteristics and implementation tracking surveys. Follow-up implementation tracking surveys were completed for 80.6% of practices. Adult patients, staff, and clinicians in family medicine, general internal medicine, and mixed-specialty practices. Practices received 9 months of practice facilitation and health information technology support, plus biannual collaborative learning sessions. This study identified practice characteristics associated with overall highest performance using area under the curve (AUC) analysis on aspirin therapy, blood pressure management, and smoking cessation CQMs. Among 178 practices, 39 were exemplars. Exemplars were more likely to be a Federally Qualified Health Center (69.2% vs 35.3%, p = 0.0006), have an underserved designation (69.2% vs 45.3%, p = 0.0083), and have higher percentage of patients with Medicaid (p < 0.0001). Exemplars reported greater use of cardiovascular disease registries (61.5% vs 29.5%,), standing orders (38.5 vs 22.3%) or electronic health record prompts (84.6% vs 49.6%) (all p < 0.05), were more likely to have medical home recognition (74.4% vs 43.2%, p = 0.0006), and reported greater implementation of building blocks of high-performing primary care: regular quality improvement team meetings (3.0 vs 2.2), patient experience survey (3.1 vs 2.2), and resources for patients to manage their health (3.0 vs 2.3). High improvers (n = 45) showed greater improvement implementing team-based care (32.8 vs 11.7, p = 0.0004) and population management (37.4 vs 20.5, p = 0.0057). Multiple strategies-registries, prompts and protocols, patient self-management support, and patient-team partnership activities-were associated with delivering high-quality cardiovascular care over time, measured by CQMs. ClinicalTrials.gov registration: NCT02515578.

Clinical Research Integration Within the Electronic Health Record: A Literature Review.

Clinical trials have become commonplace as a treatment option. As clinical trial participants are integrated into all healthcare delivery settings, organizations are tasked with sustaining specific care regimens with appropriate documentation and maintenance of participant protections within electronic health records. Our aim was to identify the common elements necessary for electronic health record integration of clinical research for optimal trial conduct and participant management. Review of literature was conducted utilizing PubMed and CINAHL to identify relevant publications that described use of the electronic health record to directly support trial conduct, with a total of 15 publications ultimately meeting inclusion criteria. Three thematic groupings emerged that categorized common aspects of clinical research integration: functional, structural, and procedural components. These components include technological requirements (platform/system), regulatory and legal compliance, and stakeholder involvement with clinical trial procedures (recruitment of participants). Without a centralized means of providing clinicians with current treatment and adverse event management information, participant injury or likelihood of withdrawal will increase. Further research is required to develop an optimal model of research-related integration within commercial electronic health records.

Electronic health record usage among nurse practitioners, physician assistants, and junior residents.

Studies demonstrate significant electronic health record (EHR) use by junior residents; however, few studies have investigated this for nurse practitioners and physician assistants (NPs/PAs). The aim of this study was to quantify the time spent on the EHR by NPs/PAs and junior residents. Electronic health record usage data were collected from April 2015 through April 2016. Monthly EHR usage was compared between NPs/PAs and postgraduate second and third year residents. Further subgroup analysis of NPs/PAs and residents from surgical or nonsurgical fields was conducted. Data for 22 NPs/PAs (16 surgical and six nonsurgical) and 125 residents (31 surgical and 94 nonsurgical) were analyzed. Nurse practitioners/physician assistants opened fewer charts per day (4.9 ± 1.5 vs. 5.4 ± 3.1), placed more orders per month, and spent more daily time on the EHR (176.5 ± 51.7 minutes vs. 152.3 ± 71.9 minutes; p < .0001). Compared with residents, NPs/PAs spent more time per patient in all categories (chart review, documentation, order entry) and in total time per patient chart (all p < .05). Comparing surgical NPs/PAs to surgical residents, findings were similar with fewer charts per day, more total daily EHR time, and more EHR time per patient in every tracked category (all p < .05). This is the first study to quantify time on the EHR for NPs/PAs. Nurse practitioners/physician assistants spent more time on the EHR than residents, and this is accentuated with surgical NPs/PAs. Electronic health record utilization appears more burdensome for NPs/PAs; however, the reason for this is unclear and highlights the need for targeted interventions.

Are specific elements of electronic health record use associated with clinician burnout more than others?

The study sought to examine the association between clinician burnout and measures of electronic health record (EHR) workload and efficiency, using vendor-derived EHR action log data. We combined data from a statewide clinician survey on burnout with Epic EHR data from the ambulatory sites of 2 large health systems; the combined dataset included 422 clinicians. We examined whether specific EHR workload and efficiency measures were independently associated with burnout symptoms, using multivariable logistic regression and controlling for clinician characteristics. Clinicians with the highest volume of patient call messages had almost 4 times the odds of burnout compared with clinicians with the fewest (adjusted odds ratio, 3.81; 95% confidence interval, 1.44-10.14; P = .007). No other workload measures were significantly associated with burnout. No efficiency variables were significantly associated with burnout in the main analysis; however, in a subset of clinicians for whom note entry data were available, clinicians in the top quartile of copy and paste use were significantly less likely to report burnout, with an adjusted odds ratio of 0.22 (95% confidence interval, 0.05-0.93; P = .039). High volumes of patient call messages were significantly associated with clinician burnout, even when accounting for other measures of workload and efficiency. In the EHR, "patient calls" encompass many of the inbox tasks occurring outside of face-to-face visits and likely represent an important target for improving clinician well-being. Our results suggest that increased workload is associated with burnout and that EHR efficiency tools are not likely to reduce burnout symptoms, with the exception of copy and paste.

State of the Science of Dimensions of Nurses' User Experience When Using an Electronic Health Record.

This integrative review synthesized relevant studies in the last decade associated to nurses' experience with the electronic health record using Robert and Lesage's dimensions of User Experience: functional, physical, perceptual, cognitive, psychological, and social. A comprehensive search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance across four electronic databases. We included articles if they were specific to nurses' electronic health record experience and workflow, published between January 2008 and June 2018, and available in English. The search resulted in 793 records with 26 articles included in the final analysis. Articles ranged from quantitative, qualitative, mixed-methods, and quality improvement studies. Across studies, the suboptimal design of the electronic health record affected the functional experience of nurses, often resulting in interruptions. The navigational design contributed to nurses' perceptual experience leading to many workarounds and workflow mismatches. Most of the studies reported overall satisfaction with the electronic health record that represented the psychological dimension of nurses' experience. Communication barriers due to the use of the electronic health record prevented nurses from having meaningful interaction with other clinicians and patients. Although nurses reported substandard user experience, many stated that reverting to a linear paper-based system was not an option.

Development of Brief Child Nutrition and Physical Activity Screening Questions for Electronic Health Record Use.

Background: To develop and test brief nutrition and physical activity screening questions for children ages 2-11 years that could be used as a pragmatic screening tool to tailor counseling, track behavior change, and improve population health. Methods: A literature review identified existing validated questions for nutrition and physical activity behaviors in children ages 2-11 years. Response variation and concurrent validity was then assessed using a mechanical Turk (MTurk) crowdsourcing survey employed in 2018. Additionally, cognitive interviews were conducted with both providers and parents of 2- to 11-year-old children to assess screening question priorities and perceived added value. Results: The literature review identified 260 questions, and 20 items were selected with expert guidance based on prespecified criteria (simplicity and potential utility for both clinical interactions during a well-child exam and population health). MTurk surveys yielded 1147 records that met eligibility criteria and revealed 6 items that had adequate response variation and were significantly correlated with parent-reported child BMI or BMI percentile, exhibiting concurrent validity. Cognitive interviews with 10 providers and 20 parents uncovered themes regarding suggestions and usability of the questions, eliminating 3 items due to parent and provider concerns. Combining quantitative and qualitative results, 3 nutrition and physical activity screening items remained for inclusion into the electronic health record (EHR). Conclusions: The three-pronged validation methodology produced a brief, 3-item child nutrition and physical activity screener to incorporate in the EHR, where it can inform tailored counseling for well-child care and be used to test associations with population health outcomes.

The influence of electronic health record use on collaboration among medical specialties

BackgroundOne of the main objectives of Electronic Health Records (EHRs) is to enhance collaboration among healthcare professionals. However, our knowledge of how EHRs actually affect collaborative practices is limited. This study examines how an EHR facilitates and constrains collaboration in five outpatient clinics.MethodsWe conducted an embedded case study at five outpatient clinics of a Dutch hospital that had implemented an organization-wide EHR. Data were collected through interviews with representatives of medical specialties, administration, nursing, and management. Documents were analyzed to contextualize these data. We examined the following collaborative affordances of EHRs: (1) portability, (2) co-located access, (3) shared overviews, (4) mutual awareness, (5) messaging, and (6) orchestrating.ResultsOur findings demonstrate how an EHR will both facilitate and constrain collaboration among specialties and disciplines. Affordances that were inscribed in the system for collaboration purposes were not fully actualized in the hospital because:(a) The EHR helps health professionals coordinate patient care on an informed basis at any time and in any place but only allows asynchronous patient record use.(b) The comprehensive patient file affords joint clinical decision-making based on shared data, but specialty- and discipline-specific user-interfaces constrain mutual understanding of that data. Moreover, not all relevant information can be easily shared across specialties and outside the hospital.(c) The reduced necessity for face-to-face communication saves time but is experienced as hindering collective responsibility for a smooth workflow.(d) The EHR affords registration at the source and registration of activities through orders, but the heightened administrative burden for physicians and the strict authorization rules on inputting data constrain the flexible, multidisciplinary collaboration.(e) While the EHR affords a complete overview, information overload occurs due to the parallel generation of individually owned notes and the high frequency of asynchronous communication through messages of varying clinical priority.ConclusionsFor the optimal actualization of EHRs’ collaborative affordances in hospitals, coordinated use of these affordances by health professionals is a prerequisite. Such coordinated use requires organizational, technical, and behavioral adaptations. Suggestions for hospital-wide policies to enhance trust in both the EHR and in its coordinated use for effective collaboration are offered.

The Influence of Electronic Health Record Use on Physician Burnout: Cross-Sectional Survey.

BackgroundPhysician burnout has a direct impact on the delivery of high-quality health care, with health information technology tools such as electronic health records (EHRs) adding to the burden of practice inefficiencies.ObjectiveThe aim of this study was to determine the extent of burnout among physicians and learners (residents and fellows); identify significant EHR-related contributors of physician burnout; and explore the differences between physicians and learners with regard to EHR-related factors such as time spent in EHR, documentation styles, proficiency, training, and perceived usefulness. In addition, the study aimed to address gaps in the EHR-related burnout research methodologies by determining physicians’ patterns of EHR use through usage logs.MethodsThis study used a cross-sectional survey methodology and a review of administrative data for back-end log measures of survey respondents’ EHR use, which was conducted at a large Canadian academic mental health hospital. Chi-square and Fisher exact tests were used to examine the association of EHR-related factors with general physician burnout. The survey was sent out to 474 individuals between May and June 2019, including physicians (n=407), residents (n=53), and fellows (n=14), and we measured physician burnout and perceptions of EHR stressors (along with demographic and practice characteristics).ResultsOur survey included 208 respondents, including physicians (n=176) and learners (n=32). The response rate was 43.2% for physicians (full-time: 156/208, 75.0%; part-time: 20/199, 10.1%), and 48% (32/67) for learners. A total of 25.6% (45/176) of practicing physicians and 19% (6/32) of learners reported having one or more symptoms of burnout, and 74.5% (155/208) of all respondents who reported burnout symptoms identified the EHR as a contributor. Lower satisfaction and higher frustration with the EHRs were significantly associated with perceptions of EHR contributing toward burnout. Physicians’ and learners’ experiences with the EHR, gathered through open-ended survey responses, identified challenges around the intuitiveness and usability of the technology as well as workflow issues. Metrics gathered from back-end usage logs demonstrated a 13.6-min overestimation in time spent on EHRs per patient and a 5.63-hour overestimation of after-hours EHR time, when compared with self-reported survey data.ConclusionsThis study suggests that the use of EHRs is a perceived contributor to physician burnout. There should be a focus on combating physician burnout by reducing the unnecessary administrative burdens of EHRs through efficient implementation of systems and effective postimplementation strategies.

Electronic Health Record Use among Ophthalmology Residents while on Call.

As electronic health record (EHR) use becomes more widespread, detailed records of how users interact with the EHR, known as EHR audit logs, are being used to characterize the clinical workflows of physicians including residents. After-hours EHR use is of particular interest given its known association with physician burnout. Several studies have analyzed EHR audit logs for residents in other fields, such as internal medicine, but none thus far in ophthalmology. Here, we focused specifically on EHR use during on-call shifts outside of normal clinic hours. In this retrospective study, we analyzed raw EHR audit log data from on-call shifts for 12 ophthalmology residents at a single institution over the course of a calendar year. Data were analyzed to characterize total time spent using the EHR, clinical volume, diagnoses of patients seen on call, and EHR tasks. Across all call shifts, the median and interquartile range (IQR) of the time spent logged into the EHR per shift were 88 and 131 minutes, respectively. The median (IQR) unique patient charts accessed per shift was 7 (9) patients. When standardized to per-hour measures, weekday evening shifts were the busiest call shifts with regard to both EHR use time and clinical volume. Total EHR use time and clinical volume were greatest in the summer months (July to September). Chart review comprised a majority (63.4%) of ophthalmology residents' on-call EHR activities. In summary, EHR audit logs demonstrate substantial call burden for ophthalmology residents outside of regular clinic hours. These data and future studies can be used to further characterize the clinical exposure and call burden of ophthalmology residents and could potentially have broader implications in the fields of physician burnout and education policy.

Effective communication and collaboration with health professionals: A qualitative study of primary care pharmacists in Western Australia.

The expanded provision of professional services by community pharmacists in the primary care setting encompasses the necessity to communicate and collaborate with other health professionals. Little is currently known about contemporary processes employed for their achievement. To explore contemporary processes employed for effective communication and collaboration between primary care pharmacists and health professionals. In-depth semi-structured interviews were conducted with pharmacists practising in primary care settings requiring varying expertise, practice experience and speciality backgrounds. Interviews were audio-recorded, transcribed verbatim and coded using NVivo version 11. Data were analysed following an inductive approach to facilitate thematic analysis. Twenty-six pharmacists were interviewed, which achieved data saturation. Five overarching themes emerged as participants described their experiences and perspectives regarding processes employed for communication and collaboration: i) tailored means of communication, ii) referral processes, iii) facilitators for effective interactions, iv) barriers to effective interactions, and v) implementation of a national digital health record. Participants acknowledged that the changing landscape of the Australian health system affected communication and collaboration with other health professionals. The changes resulted in participants' acceptance of a multidisciplinary approach to healthcare, which was contingent upon effective communication, interactions and relationships with other health professionals. Varying levels of formality and characteristics of referrals were identified, however the nature of the communication was tailored to the individual scenario or circumstance that was considered appropriate. Pharmacists exercised judgment on a case-by-case basis when tailoring the means of communication. The establishment of a consistent and structured two-way referral process between health professionals within the primary care setting is important, which includes use of the national digital health record. Increased awareness and appreciation of each health professional's roles and expertise would further enhance inter-professional collaboration.

Association of Electronic Health Record Use With Physician Fatigue and Efficiency

The use of electronic health records (EHRs) is directly associated with physician burnout. An underlying factor associated with burnout may be EHR-related fatigue owing to insufficient user-centered interface design and suboptimal usability. To examine the association between EHR use and fatigue, as measured by pupillometry, and efficiency, as measured by mouse clicks, time, and number of EHR screens, among intensive care unit (ICU) physicians completing a simulation activity in a prominent EHR. A cross-sectional, simulation-based EHR usability assessment of a leading EHR system was conducted from March 20 to April 5, 2018, among 25 ICU physicians and physician trainees at a southeastern US academic medical center. Participants completed 4 simulation patient cases in the EHR that involved information retrieval and task execution while wearing eye-tracking glasses. Fatigue was quantified through continuous eye pupil data; EHR efficiency was characterized through task completion time, mouse clicks, and EHR screen visits. Data were analyzed from June 1, 2018, to August 31, 2019. Primary outcomes were physician fatigue, measured by pupillometry (with lower scores indicating greater fatigue), and EHR efficiency, measured by task completion times, number of mouse clicks, and number of screens visited during EHR simulation. The 25 ICU physicians (13 women; mean [SD] age, 32.1 [6.1] years) who completed a simulation exercise involving 4 patient cases (mean [SD] completion time, 34:43 [11:41] minutes) recorded a total of 14 hours and 27 minutes of EHR activity. All physician participants experienced physiological fatigue at least once during the exercise, and 20 of 25 participants (80%) experienced physiological fatigue within the first 22 minutes of EHR use. Physicians who experienced EHR-related fatigue in 1 patient case were less efficient in the subsequent patient case, as demonstrated by longer task completion times (r = -0.521; P = .007), higher numbers of mouse clicks (r = -0.562; P = .003), and more EHR screen visits (r = -0.486; P = .01). This study reports high rates of fatigue among ICU physicians during short periods of EHR simulation, which were negatively associated with EHR efficiency and included a carryover association across patient cases. More research is needed to investigate the underlying causes of EHR-associated fatigue, to support user-centered EHR design, and to inform safe EHR use policies and guidelines.

Multicenter Analysis of Electronic Health Record Use among Ophthalmologists

Order entry via mobile client was associated with decreased after-hours EHR use in a cohort of 139 academic ophthalmologists. EHR audit log data can provide insights into strategies for optimizing efficiency of EHR use.

Stress related to electronic health record (EHR) use among oncology trainees: A quality improvement study to optimize information gathering.

11015 Background: Poor EHR usability is associated with physician burnout [1]. Oncology providers are tasked with coordinating data from multiple sources/tabs within an EHR (biomarkers, genetic data, imaging, etc.) to make treatment plan decisions. It is hypothesized that oncology trainees will have decreased stress using an EHR tool to optimize data gathering. Methods: This single-institution quality improvement study aims to decrease the time and stress associated with navigating the EHR to review/document laboratory data among first-year clinical oncology fellows rotating on consult services at The Mount Sinai Hospital as measured by self-reported survey data. An EHR tool was built that pulls into the note a drop-down list of user-selectable laboratory panels grouped according to hematologic/oncologic disease presentations. A survey was sent to all fellows in the program to assess attitudes toward the EHR. All 1st-year fellows were given access to the EHR tool as they are the ones who primarily rotate on consult services. After 3 months, a follow-up survey was sent to 1st-year clinical fellows to assess satisfaction with the EHR intervention. Results: For the baseline survey, there are a total of 17 respondents (response rate 77%). 70.6% of fellows believe using the EHR increases their level of stress. The most prevalent reasons cited for frustrations with the EHR are “Hard to read other providers’ notes” (82.4%), “Gathering information from multiple different pages” (76.5%), “Increased documentation requirements” (76.5%), “Inability to quickly navigate the system” (64.7%). For the follow-up survey targeting 1st-year fellows, there are a total of 6 respondents (response rate 100%). 5 fellows tried the EHR tool at least once. Of those 5 fellows, 100% use it daily in clinical practice while on consult services, believe it makes notes more legible, believe it saves time spent in chart review, and believe it decreases their stress associated with navigating the EHR. Conclusions: A majority of clinical oncology fellows believe that the EHR contributes to their stress. The reasons cited suggest that interventions that optimize note-writing and chart-reviewing may decrease stress. The majority of fellows who used this EHR tool believe the tool improved their efficiency and stress levels. This suggests more widespread use of this tool among oncology clinicians may contribute to wellness although further studies to increase utilization must be taken.