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Rhetoric and Economics of User Attention in EHR Documentation
- 1. The Rhetoric and Economics of User Attention in EHR Clinical Documentation In a Manner of Speaking….. Susan Rauch, Ph.D. Texas Tech University | susan.rauchttu@gmail.com Conference: Transatlantic Connections Medical Humanities Bundoran, Ireland | January 11, 2017
- 2. 2© Duarte, Inc. 2014 + EHR decision –making + Technology Functionality + Transaction Hazards + Common User Challenges + EHR Literacy + Rhetorical Value of Clinical Narrative + Economics of Attention + Rhetoric of Health and Medicine + Applied Rhetoric + Transaction Hazards in e-Narrative + Sociotechnical Systems Theory (STS) for HIT + HITECH/Meaningful Use + Economics of Attention (Rhetorical approach to economics theory) + Applied Rhetoric (Text production and consumption) + STS Theory (HIT Model) RESEARCH PRESENTATION OVERVIEW + Allied Health Professional + Industry Experience + Personal Experience + Graduate Research + Hospital Research My Research Journey Research Questions Literature Review Theoretical Frameworks 01 02 03 04 05 + Printing and Projecting Slidedocs + Distributing Slidedocs + Case Study: From Cinematic to Slidedoc + Spread Big Ideas With Slidedocs Research Methods + Scarcity of Attention + Alert Fatigue + Charting by Exception + Automated Technology + Training Initiatives + UX Research + Interviews/Observations + Contextual Analysis + 3D/8D Assessment Models Conclusion and Next Steps 06 07 Key Findings
- 3. 3© Duarte, Inc. 2014 Allied Health Professional: Dental Graduate School: MA English MA Tech Comm Allied Health: Transcriptionist, Editor, Marketing Research 4-yr Study Economics of User Attention EHR Clinical Documentation Graduate School: Ph.D. TCR MY RESEARCH JOURNEY 01
- 4. MY RESEARCH JOURNEY: Evolution of Clinical and eHealth Documentation CHIEF COMPLAINT HISTORY OF PRESENT ILLNESS (HPI) PAST MEDICAL HISTORY (PMH) MEDICATIONS ALLERGIES: PENICILLIN FAMILY HISTORY: Father high BP. Mother basal cell carcinoma. SOCIAL HISTORY: Nonsmoker. Alcohol 1 drink q.d. REVIEW OF SYSTEMS General: no fever, no chills, no sweats Cardiovascular ENT Respiratory GI Neuro GU PHYSICAL EXAM Vitals: BP 108/58, HR 72, RR 12, O2 95%. HEENT: Neck Cardio: No murmur Skin LABS WBC RBC EKG PROBLEM LIST (current symptoms/reason for visit) 01
- 5. Images: Hosp. B Usability Testi Plan LetDoctorsBeDoctors MY RESEARCH JOURNEY: Evolution of Clinical and eHealth Documentation 01
- 6. RESEARCH QUESTIONS 1. How does EHR technology influence health professionals’ decision-making regarding clinical documentation best practices (and challenges) that affect the overall integrity of the EHR clinical narrative? 2. In what way does the accessibility and functionality of EHR technology in the workplace influence EHR-end users’ communication practices? Sub-Questions ? Common challenges end-users encounter in EHR clinical documentation leading to transaction hazards in EHR narratives? ? How can technical-health communicators add value in the improvement of eHealth documentation practices that affect the capture and interpretation of EHR- generated narratives? 02
- 7. Economics of Attention: Rhetorical approach to attention economics theory. Competition for attention as a scarce resource. How style in electronic documentation attracts or regulates attention. (Lanham) Sociotechnical Systems: User challenges associated with EHR technologies. Approach to users workflow and interaction with health information technologies (HIT). (Sittig and Singh) Applied Rhetoric: Rhetorical and competitive value of electronic text. How technical communicators create value. (Carter) LITERATURE REVIEW Rhetoric of Healthcare and Medicine: “Strategies that influence medical authorship [in illness narratives].” (Segal) “How we interpret and receive texts as rhetoric.” (Heifferon and Brown) Transaction Hazards: EHR errors of omission and commission (Yackel and Embi) Clinicians challenges with electronically written communication (Johnson et al.) LITERATURE REVIEW & APPLIED THEORETICAL FRAMEWORKS 03 04
- 8. RESEARCH METHODS Data Collection Interviews: 21-34 questions (dependent on specialty) 36 Health Professionals, 2 Hospitals (NW and Central Texas) Survey: 11 Questions 42 Responses Email/Qualtrics Distribution: HFMA and ACDIS* Contextual-Rhetorical Analysis: EHR Testing Event 10 Usability Heuristics for EHR Task Performance (Nielsen) Defined Verbal/Nonverbal Rhetorical Units of Value (Blythe) *HFMA: Health Finance Management Association Membership email LISTSERVE *CDIS: Association for Clinical Documentation Improvement Specialists Membership email LISTSERVE05
- 9. RESEARCH METHODS *HFMA: Health Finance Management Association *CDIS: Association for Clinical Documentation Improvement Specialists QUALITATIVE STUDY Contextual-Rhetorical Analysis Observation: EHR Testing Event 10 Usability Heuristics for EHR Task Performance (Nielsen) Defined Verbal/Nonverbal Rhetorical Units of Value (Blythe) SURVEY 11 Questions 42 Responses Qualtrics Surve Tool HFMA and ACDIS* Listserve INTERVIEWS 1-34 questions 36 Health Professionals 2 Acute Care Hospitals (NW and Central Texas) Coding: N-Vivo and Doc Tools Saldana’s Qualitative Methods 05
- 10. RESEARCH METHODS: KEY FINDINGS Crossweaving (overlap) of 4 emergent themes 06
- 11. AUTOMATED TEXT AND TECHNOLOGY ARE YOU PAYING ATTENTION? 06
- 12. KEY FINDINGS 06 Other Comparative Studies on Safety Alerts and Alert Fatigue: 1 Month Frequency Stats ICU CPOE Monitors
- 13. HOW ATTENTION STRUCTURES COMPETE FOR ATTENTION VideoImages: Cerner Store EHR is Health EHR is ROI EHR is Narrative ICD is Diagnosis (or Health) ICD is ROI ICD-9 463 is acute tonsillitis ICD-10CM J18.9 is pneumonia KEY FINDINGS 06
- 14. Workflow Models for EHR Narrative Research RECOMMENDATIONS AND FUTURE RESEARCH
- 15. 8D Sociotechnical Model – Sittig And Singh Measurement for Sociotechnical Challenges in HIT Systems Hardware and Software Infrastructure that refers to equipment used to power, support, and operate clinical applications Clinical Content Textual or numeric data and images that constitute “language of clinical applications.” Human Computer Interface All aspects of the computer that users can see, touch, and hear, as they interact with it. People Everyone who interacts in some way with the system, from developer to end user including potential patient-users. Workflow Communication Processes and steps involved in assuring that patient care tasks are carried out effectively. Internal Organization Features Includes policies, procedures, and cultural considerations External Rules and Regulations External forces that place constraints on the design, development, implementation, use, and evaluation of HIT. Measurement and Monitoring Process of measuring and evaluation (quality assurance and control) both intended and unintended consequences of HIT implementation and use. WORKFLOW MODELS FOR EHR NARRATIVE RESEARCH
- 16. Handout: http://www.slideshare.net/SusanRauch1/rauch-transatlantic-connections-med-humanities-handout WORKFLOW MODELS FOR EHR NARRATIVE RESEARCH
- 17. CONCLUSION AND NEXT STEPS Interviews: Talk to Physicians! And EHR vendors/TC’s – To better understand best practices in EHR usability/documentation decision-making. Usability/UX Test Training Initiative: Academic SIM EHR as clinician training tool at point-of-care. Usability/UX Testing: Observation and Mouse tracking task performance at point- of-care (usability software). Optimally with/comparing different EHR vendor/hospital systems. Observation of EHR Development: Text and Technology. Role of technical communicator. Rhetorical Analysis: EHR vendor competition; arguments in provider EHR decision- making. 07
- 18. NEXT STEPS: FUTURE RESEARCH Recommend Training Initiatives To improve EHR digital literacy and communication practices Improve on scarcity of attention to text and technologies Text & Technology: Applied 3D and 8D Assessment Models To assess the competition of and sociotechnical challenges with EHR text and technology re: decision-making processes of healthcare providers and users Evaluate rhetorical value of competitive attention structures e.g. automated technology, alert fatigue, coding structures Assess rhetorical value of TC decision-making in the development and distribution of EHR systems (production-reception-social circumstance) Data Exchange between hospital facilities (presently not universalized - proprietary) 07
- 19. More About Me: Susan Rauch, Ph.D. susan.rauchttu@gmail.com susanrauch.wordpress.com
- 20. MY SCHOLARSHIP PUBLISHED ARTICLES AND WORKS IN PROGRESS Accepted "The Accreditation of Hildegard von Bingen as Medieval Female Technical Writer." Journal of Technical Writing and Communication 42.4 (2012): 393-411. Non-Refereed “Rhetoric of Health and Medicine Wiki.” Contributing collaborator, co-author and editor. “Healthcare Literacy Guide for Aged and Disabled.” Texas State University-San Marcos. Service-Learning Initiative. (digital health promotion guide) Under Review “Annotating Time and Place: Mapping the Collective and Cultural Memory of Anna Coleman Ladd During the Great War.” “IRB Problems and Solutions in Health Communication Research.” (co-authored by Carie King, Kristin Bivens, Erin Pumroy, Susan Rauch, Amy Koerber) In Preparation “Dialogues from an Online Nursing Community: Identifying Barriers, Overcoming Ethical Challenges of Nurses with Disabilities” ( “It’s All in the Literature: Disability and Public Health Perceptions of Bohemian and Czech Immigrants in 19th through 20th Century Midwest America “The Rhetoric and Economics of User Attention in EHR Clinical Documentation and Usability Best Practices” “Educating the Educator: A Parent’s Perspective of Psychopharmacology and Tourette Syndrome “Evaluating the role of disability studies and assistive communication technologies in the teaching of technical communication and instructional design.” “Metaphorically and Medically Speaking… The Rhetoric and Economics of Attention of Journey Metaphor in eHealth Management Service Organizations’ White Papers.” (written and visual strategies in argumentation) PRESENTATIONS: NATIONAL AND INTERNATIONAL “In a Manner of Speaking: Using Rhetoric and Economics of User Attention in the Study of eHealth Clinical Narrative Constructio.” Transatlantic Connections: Equality Emerging: Session: The Field of Medical Humanities' Influence on Healthcare Access and Delivery. Bundoran, Donegal, Ireland Drew U. 2017 “Rhetoric and Economics of User Attention in the Documentation of EHR-generated Clinical Narratives.” ATTW. Graduate Award Recipient. Houston, TX 2016 “Rhetoric and Economics of eHealth Records: The risk and value of economizing language in the digitization of patient narratives.” Conference on College Composition and Communication (CCCC). Tampa, FL 2015 “Out of the Classroom, Into the Workplace: Simulation and Assimilation of eHealth Curricula.” CCCC. Indianapolis, IN 2014 “Nurses with Disabilities: Identifying Barriers, Overcoming Ethical Challenges (Analyzing Dialogues in an Online Nursing Community),” 4th Annual Conference in Values in Medicine, Science & Technology. Dallas, TX U. of North Texas 2014 “Annotating Time and Place: A collective and cultural memory of the Great War from the Anna Coleman Ladd Papers: American Red Cross Studio for Portrait-Masks File, 1914-1925,” War Memories Conference. Rennes, France EU of Brittany 2014 “Corpus and Presenter Tool: Identifying trends and transitions in page design and genre in Late Medieval through Early Modern medical texts,” 48th International Congress of Medieval Studies Kalamazoo, MI WMU. 2013 “The Paston Letters (1422-1509): A Prosopography of Late Medieval to Early- Modern Friendship,” 46th International Congress of Medieval Studies. Kalamazoo, MI WMU 2011 REGIONAL INVITED TALK Dept. of Psychology and Special Education. School of Education. Topic: “Educating the Educator: A Parent’s Perspective of Psychopharmacology and Tourette Syndrome.” San Marcos, TX TxState U. 2011
- 21. Carter, [Joyce] Locke, ed. Market matters: Applied rhetoric studies and free market competition. Hampton Press (NJ), 2005. Heifferon, Barbara, and Stuart Cameron Brown, eds. Rhetoric of healthcare: Essays toward a new disciplinary inquiry. Hampton Press, 2008. Lanham, Richard A. The economics of attention: Style and substance in the age of information. University of Chicago Press, 2006. Nielsen, Jakob, and Rolf Molich. "Heuristic evaluation of user interfaces."Proceedings of the SIGCHI conference on Human factors in computing systems. ACM, 1990. Segal, Judy. Health and the rhetoric of medicine. SIU Press, 2005. Segal, Judy, Sittig, Dean F., and Hardeep Singh. "A new sociotechnical model for studying health information technology in complex adaptive healthcare systems."Quality and Safety in Health Care 19.Suppl 3 (2010): i68- i74. Scott, Blake; Segal, Judy Z.; and Keranen, Lisa. "The Rhetorics of Health and Medicine: Inventional Possibilities for Scholarship and Engaged Practice." Poroi 9, Iss. 1 (2013): Article 17. Wachter, Bob. Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco (UCSF) Aug. 2015. IHI.org Derkatch and Segal Realms of Rhetoric in Health and Medicine Cerner Store. Cerner.com. 2016. AllScripts. AllScripts.com. 2016 CONSULTED SOURCES
- 22. EXTRA SLIDES
- 23. ATTENTION STRUCTURES: AUTOMATED TEXT AND TECHNOLOGY “How we pay attention to the world of [digital] information and hence what use we can make of it” (Lanham 14).
- 24. PURPOSE OF STUDY: So what? To understand the rhetorical value of human attention in eHealth clinical documentation due to information overload. Assess how and why clinicians’ attention is challenged by EHR technologies that lead to transaction hazards in EHR-generated clinical narratives. Explore end-user perspectives about EHR clinical-documentation practices
- 25. CONTEXUAL-RHETORICAL ANALYSIS: Key Findings – Task Performance Image Source: AllScripts Maternity Attention Structures: Verbal/nonverbal signals (means of expression) in the EHR narrative constructs
- 26. Attention Structures: What is Alert Fatigue? When clinicians become desensitized to safety alerts, and as a result ignore or fail to respond appropriately to such warnings” (AHRQ 2015) “The near-constant, often-annoying profusion of system alerts” such as audio and visual warnings that pop up in the screen” (Miliard 2015).
- 27. AUTOMATED TEXT AND TECHNOLOGY: Computerized Pop Up (Examples) 2. Rx Safety Alert Images: CabellHuntingtonHospital 1. Communication Type Menu (Noted in Task Performance Results) Image: Cerner Store
- 28. AUTOMATED TEXT AND TECHNOLOGY: Usability Test Frequency of Safety Alerts 14x’s 30 min From: UX EHR Testing Event: Task Performance/Contextual-Rhetorical Analysis
- 29. LIMITATIONS OF RESEARCH No Physician Participation Unable to Observe EHR Navigation at Point-of-Care Communication difficulties with EHR vendors Small Survey Population
Hinweis der Redaktion
- Kenneth Burke said: Every way of seeing is a way of not seeing” According to Richard Lanham this meant that “paying attention in one way means you cannot pay attention in another. And the manner of attention changes the object” [in other words]“What is clear “style” to one sense is opaque to another. (Lanham 184) SLIDE 1: My dissertation shows that when users of electronic spaces (in eHealth documentation) cannot effectively pay attention to the digital content presented, the user of that information may commit transaction hazards in written communication such as errors of omission or commission due to scarcity of human attention. The assessment of EHR attention structures is important in order to understand how transaction hazards occur in EHR documentation that may compromise the rhetorical value and integrity of the EHR’s clinical narrative construct. I present an argument that technical communicators of digital text content in EHR development must first assess the rhetorical value. of attention structures as way to understand the needs and literacy levels of the intended user or readership. Only through such an assessment can technical communicators understand the value of the electronic text as a rhetorical product thus not compromising its integrity.
- Kairotic shifts and Oscillation in clinical documentation structure From Linear to Non-Linear. *****According to Lanham: Because of the unstructured format of the EHR’s narrative content, clinicians are not only subjected to information overload but what Lanham describes as the “oscillation between two ways of seeing” (80). While the navigation menu allows users to toggle back and forth, additional challenges arise with the constant presence of numerous dropdown alerts and menus, which disrupt the attention and flow of the clinical documentation process. According to the AHRQ, health information system interfaces should include “representations of systems, processes, and items that exist in the real world” (Armijo, McDonnell, and Werner 9). The report specifically highlights the importance of understanding real-world health information design in order to avoid occurrences of user error. Design should reflect physician cognition and environmental stressors. Physicians as experts in cognitively demanding, time constrained, and highly interruptive environments operate in what is known as rules-based decision-making mode. This method of decision making is fast, economical of effort, and based on well-encoded individualized "procedural knowledge." The nature of the clinical care environment puts the physician at risk for information overload errors such as break-in-task or loss of activation. EHR user interface design should be engineered to support and enhance rules-based decision making by highly practiced experts who do not all use a single or consistent task structure. The form and timing of information presentation must respect the risks of break-in-task and loss of activation events that can be caused by introducing competing tasks and distracting information into the already-saturated workflow. (10)
- Kairotic shifts and Oscillation in clinical documentation structure From Linear to Non-Linear. *****According to Lanham: Because of the unstructured format of the EHR’s narrative content, clinicians are not only subjected to information overload but what Lanham describes as the “oscillation between two ways of seeing” (80). While the navigation menu allows users to toggle back and forth, additional challenges arise with the constant presence of numerous dropdown alerts and menus, which disrupt the attention and flow of the clinical documentation process. Play first 1-2:36 min of LetDoctorsBeDoctors “EHR State of Mind” Rap Video Examples of navigation menus. Non-linear. According to the AHRQ, health information system interfaces should include “representations of systems, processes, and items that exist in the real world” (Armijo, McDonnell, and Werner 9). The report specifically highlights the importance of understanding real-world health information design in order to avoid occurrences of user error. Design should reflect physician cognition and environmental stressors. Physicians as experts in cognitively demanding, time constrained, and highly interruptive environments operate in what is known as rules-based decision-making mode. This method of decision making is fast, economical of effort, and based on well-encoded individualized "procedural knowledge." The nature of the clinical care environment puts the physician at risk for information overload errors such as break-in-task or loss of activation. EHR user interface design should be engineered to support and enhance rules-based decision making by highly practiced experts who do not all use a single or consistent task structure. The form and timing of information presentation must respect the risks of break-in-task and loss of activation events that can be caused by introducing competing tasks and distracting information into the already-saturated workflow. (10) In Lanham’s assessment of competitive attention structures, he asks: What device do I choose? And what stylistic rules come with it? . . . . How, when you are ‘writing’ in the electronic space, do you decide when to use words, when images, and when sounds? Or in what combination” (81). Similar to my comparative analysis of the linear, traditional printed text in clinical documentation, Lanham argues that in print text the linear “order of presentation does not” change . . . all your attention goes to the meaning of the text, and the eye is always attracted to movement” (82-83). He further points out that “when you look at images, still or moving, you apprehend them not element by element, as you read words, but all at once, as a single entity” (83). With the electronic text, the text “often moves in three-dimensional space” therefore becoming what Lanham describes as “dimensional typography” (93; 95). In the development of technical communication for eHealth technologies, technical writers need to understand new trends in the discipline eHealth communication designed for clinical written communication. Trends include knowing “core competency skills” of the audience (clinician users) that includes the use of words and images to inform, persuade, and “help people accomplish their goals” (52). My research results also indicate that in the discussion of economics of attention this oscillation between dimensions of attention structure-types becomes problematic.
- Research Questions (Slide 4) This slide should clearly state the research questions. Some people, especially those doing comparative or quantitative research, may also have working hypotheses. But all of us have research questions. Moreover, this slide will get lots of editing over time as you come across better words to substitute and as your research agenda evolves. Ideally your research interests can be expressed several ways: first through a big-picture research question that will be abstract and general, broadly appealing, even, and understandable for people who aren’t experts in your subfield or who are interested in your theory ideas but not really your specific case study or research domain; second, through a more focused question that is specific to your period of inquiry, your case study, your population, your sample or your artifact. For example, this might be the difference between “What does the concentration of media ownership mean for deliberative democracy?” and “What were the causes and consequences of the concentration of television broadcast licenses in the United States between 1990 and 2008?” While this slide is up, you also have a unique opportunity to intrigue the audience with a weird problem, a perplexing quote, a puzzling situation. The details of the narrative don’t need to go on the slide -- you entrance us with an oxymoron, riddle or highly problematic quote from your text or your fieldwork. Or an unresolved question that your peers have missed. It should be something that will make someone in the audience heckle “no!” or “neat!”
- To answer my research questions, I lean on Lanham’s rhetorical approach to attention economics as well as scholarship and theories in the rhetoric of health and medicine. In more recent years, most research in the rhetoric of health and medicine has shifted toward the study of eHealth communication, specifically the relationships among human interaction, computer literacy, and digital text content in medical discourses. 8D model for the study of health information technology workflow and communication e.g. clinical content and computer/human interface 3D model to evaluate the rhetorical value of digital texts from production, to distribution, to readership consumption/communication (social interaction with text) (see handout) – Determining rhetorical and competitive value of electronic documents e.g. text creation, movement of text between organizations, why texts work better in different disciplines, and how the text has history. (Carter 44)
- 10 Usability Heuristics for EHR Task Performance (Nielsen) Defining Rhetorical Units of Value (Blythe) Rhetorical Analysis: Rhetorical approach to attention economics and digital text Identifies rhetorical strategies in the organization of EHR template. Recommended Models: 8D model for the study of health information technology workflow and communication e.g. clinical content and computer/human interface 3D model to evaluate the rhetorical value of digital texts from production, to distribution, to readership consumption/communication (social interaction with text) (see handout) C-R: 10 Usability Heuristics for Interface Design (Nielsen and Molich) Defining and coding units of analysis in Web design research (Blythe) Each method of inquiry in this chapter uses varying aspects of Nielsen and Blythe’s models to support the analysis ofusers’ perspectives to determine how “cognitive and environmental stressors” affect EHR usability and functionality in the development of clinical content. Nielsen’s approach is particularly useful when placing the context of EHR within the situation of a testing event, analyzing user and task performance. Blythe requires the coder to “make an interpretation to infer purpose, and to decide when purpose or audience has shifted” (215). Blythe suggests analyzing digital text by coding manifest or latent content (215). Manifest content is measured quantitatively and represents “observable phenomena in text . . .such as words, phrases, clauses, and t-units” (215). Latent content is a rhetorical unit of value that represents the “underlying elements on the surface of the message.” In my contextual rhetorical analysis and interview findings it was noted that many clinicians rely on automated text and technology to document information. In other words, they go through the motions by not paying close attention to a limited choice of information presented. Charting by exception is one disadvantage that participants noted, specifically in the interview results. Recall practice of “recall” is problematic because “people just recall all the way down [the electronic chart] without even looking . . . it’s kind of cheating. I think that can cause a lot of errors.” This response alludes to the fact that technology supersedes the act of critical thinking when documenting patient information. It also infers that clinicians are too dependent on charting by exception during the clinical documentation process. For example, the participant stated: It’s where you can push function 5 or a key, any one of the . . . and it’ll pull up, like say, unit dose s/l Albuterol, you can recall it and it’ll pull it in that charting for you. It’s a key that is supposed to help you, but some people abuse it. CBE In EHR documentation, charting by exception is a documentation practice driven by clinicians’ reliance on automated technology instead of critical thinking skills to document clinical information. The With charting by exception, the clinician does not narrate a full account of his or her findings, but instead relies on automated technology to assist in recording the patient’s condition based on pre-determined norms or criteria. If the patient’s diagnosis or problem falls outside the pre-determined norms for the condition, and the physician does not manually add that information, the documented assessment results in an incomplete narrative or story that otherwise would have been included had the clinician handwritten or charted on paper. is incorrect or ambiguous in diagnosis . Automated technology includes but is not limited to dropdown and default menus, alerts, fields, and checkboxes. Charting by exception is defined as: A shorthand method for documenting normal findings, based on clearly defined standards of practice and predetermined criteria for nursing assessments and interventions. Only significant findings or exceptions to the predefined norms are documented in longhand notes. MedLeague, which is a legal organization that advocates for nursing professionals and at-risk documentation, also defines the risks of charting by exception. When a healthcare provider charts by exception, it means that only exceptions to these baseline findings would be charted. If nothing was charted, the patient’s status is assumed to match the baseline . . . minimizing documentation can be risky and can be filled with potential liabilities if the charting definitions are unclear or if staff uses this as a lazy way to document. It is also extremely difficult to design the definitions so that exceptions will be well documented [for example] a temptation to short cut charting such as just “cutting and pasting” findings in an electronic medical records. Basically, if the automated information is not a norm for the patient and the clinician does not chart anything different, the narrative is assumed complete even though there could be another undocumented assessment that could compromise patient safety. If the status is never charted, it is therefore never seen, and from a coding and revenue integrity standpoint never addressed. it was never done. From a legal standpoint, the practice of charting by exception, if used incorrectly, could compromises the accuracy and integrity of the patient narrative. The practice of charting by exception (CBE), through the use of automated technology, minimizes the documentation process by limiting, excluding, or not expanding on the written narrative. Participants raised the same concern in the interview results where they felt charting by exception (CBE) influences clinicians to “rely on technology to complete a task” and not critically think about what they are documenting. According to the findings of my research, CBE within the context of the EHR influences clinicians to rely on pre-determined information presented in the automated menus in turn affecting clinicians’ decisions about what to include or not include in the overall narrative construct. According to NSO, a service organization that manages liability insurance coverage for nurses, charting by exception “demands sound judgment and common sense in determining what’s in and what’s out.” If the clinicians are in a hurry and do not understand the functionality of EHR technology, how it works within the process of documenting patient information, critical patient information may not get documented due to a lack of attention to detail in the narrative. This finding is again directed to clinicians not paying attention to the necessary, additional narrative details when documenting patient information. Based on my research findings, clinicians’ lack of understanding about the functionality of EHR technology is evident with how they respond to automated safety alerts and popup menus. This type of automated technology also represents a type of attention structure that encourages alert fatigue – “the near-constant, often-annoying profusion of system alerts” as audio and visual warnings that pop up in the screen.”
- 10 Usability Heuristics for EHR Task Performance (Nielsen) Defining Rhetorical Units of Value (Blythe) Rhetorical Analysis: Rhetorical approach to attention economics and digital text Identifies rhetorical strategies in the organization of EHR template. Recommended Models: 8D model for the study of health information technology workflow and communication e.g. clinical content and computer/human interface 3D model to evaluate the rhetorical value of digital texts from production, to distribution, to readership consumption/communication (social interaction with text) (see handout) C-R: 10 Usability Heuristics for Interface Design (Nielsen and Molich) Defining and coding units of analysis in Web design research (Blythe) Each method of inquiry in this chapter uses varying aspects of Nielsen and Blythe’s models to support the analysis ofusers’ perspectives to determine how “cognitive and environmental stressors” affect EHR usability and functionality in the development of clinical content. Nielsen’s approach is particularly useful when placing the context of EHR within the situation of a testing event, analyzing user and task performance. Blythe requires the coder to “make an interpretation to infer purpose, and to decide when purpose or audience has shifted” (215). Blythe suggests analyzing digital text by coding manifest or latent content (215). Manifest content is measured quantitatively and represents “observable phenomena in text . . .such as words, phrases, clauses, and t-units” (215). Latent content is a rhetorical unit of value that represents the “underlying elements on the surface of the message.” In my contextual rhetorical analysis and interview findings it was noted that many clinicians rely on automated text and technology to document information. In other words, they go through the motions by not paying close attention to a limited choice of information presented. Charting by exception is one disadvantage that participants noted, specifically in the interview results. Recall practice of “recall” is problematic because “people just recall all the way down [the electronic chart] without even looking . . . it’s kind of cheating. I think that can cause a lot of errors.” This response alludes to the fact that technology supersedes the act of critical thinking when documenting patient information. It also infers that clinicians are too dependent on charting by exception during the clinical documentation process. For example, the participant stated: It’s where you can push function 5 or a key, any one of the . . . and it’ll pull up, like say, unit dose s/l Albuterol, you can recall it and it’ll pull it in that charting for you. It’s a key that is supposed to help you, but some people abuse it. CBE In EHR documentation, charting by exception is a documentation practice driven by clinicians’ reliance on automated technology instead of critical thinking skills to document clinical information. The With charting by exception, the clinician does not narrate a full account of his or her findings, but instead relies on automated technology to assist in recording the patient’s condition based on pre-determined norms or criteria. If the patient’s diagnosis or problem falls outside the pre-determined norms for the condition, and the physician does not manually add that information, the documented assessment results in an incomplete narrative or story that otherwise would have been included had the clinician handwritten or charted on paper. is incorrect or ambiguous in diagnosis . Automated technology includes but is not limited to dropdown and default menus, alerts, fields, and checkboxes. Charting by exception is defined as: A shorthand method for documenting normal findings, based on clearly defined standards of practice and predetermined criteria for nursing assessments and interventions. Only significant findings or exceptions to the predefined norms are documented in longhand notes. MedLeague, which is a legal organization that advocates for nursing professionals and at-risk documentation, also defines the risks of charting by exception. When a healthcare provider charts by exception, it means that only exceptions to these baseline findings would be charted. If nothing was charted, the patient’s status is assumed to match the baseline . . . minimizing documentation can be risky and can be filled with potential liabilities if the charting definitions are unclear or if staff uses this as a lazy way to document. It is also extremely difficult to design the definitions so that exceptions will be well documented [for example] a temptation to short cut charting such as just “cutting and pasting” findings in an electronic medical records. Basically, if the automated information is not a norm for the patient and the clinician does not chart anything different, the narrative is assumed complete even though there could be another undocumented assessment that could compromise patient safety. If the status is never charted, it is therefore never seen, and from a coding and revenue integrity standpoint never addressed. it was never done. From a legal standpoint, the practice of charting by exception, if used incorrectly, could compromises the accuracy and integrity of the patient narrative. The practice of charting by exception (CBE), through the use of automated technology, minimizes the documentation process by limiting, excluding, or not expanding on the written narrative. Participants raised the same concern in the interview results where they felt charting by exception (CBE) influences clinicians to “rely on technology to complete a task” and not critically think about what they are documenting. According to the findings of my research, CBE within the context of the EHR influences clinicians to rely on pre-determined information presented in the automated menus in turn affecting clinicians’ decisions about what to include or not include in the overall narrative construct. According to NSO, a service organization that manages liability insurance coverage for nurses, charting by exception “demands sound judgment and common sense in determining what’s in and what’s out.” If the clinicians are in a hurry and do not understand the functionality of EHR technology, how it works within the process of documenting patient information, critical patient information may not get documented due to a lack of attention to detail in the narrative. This finding is again directed to clinicians not paying attention to the necessary, additional narrative details when documenting patient information. Based on my research findings, clinicians’ lack of understanding about the functionality of EHR technology is evident with how they respond to automated safety alerts and popup menus. This type of automated technology also represents a type of attention structure that encourages alert fatigue – “the near-constant, often-annoying profusion of system alerts” as audio and visual warnings that pop up in the screen.”
- My Findings (Slides 9 and 10) Your more nuanced understanding of the problem at hand is based on your expertise: your fieldwork, your considered assessment of a media text, your collection and assessment of data, or your cross-case comparison. You get to justify your methodological and epistemological approach, and do your reading of evidence. There is a lot of variety about what can go in these slides, but they can be dedicated to you or your project. These slides can be about findings from your specific field site, artifact or data analysis. In other words, they should be the answers you would offer to your second very specific research question. Scarcity of attention is influenced by three main factors task performance, EHR functionality, and fragmented narrative. One significant finding is how attention structures such as automated technology (visual and textual cues) in the electronic medical record or template contribute transaction hazards in the EHR-generated narrative during the clinical documentation process. Attention Structures: How we pay attention to the world of [digital] information and hence what use we can make of it. (Lanham 14) 80/20 rule Alert fatigue is common. Clinicians generally override the vast majority of CPOE warnings, even "critical" alerts that warn of potentially severe harm. There is less literature on other types of warnings, but it is likely that rates of overriding or ignoring warnings in other settings are also high. Rhetorical strategies that influence decision-making practices during the medical authorship of eHealth documentation (see handout) 2nd cycle pattern coding is to identify common challenges that affect decision-making during the clinical documentation process and EHR-narrative construction. Pattern coding is a method that groups categories from the larger 1st cycle coding and chunks them into “a smaller number of categories, themes, or concepts” (Saldana 236). All three methods of inquiry reveal that scarcity of attention in relationship to automated technology was a leading cause of transaction hazards in electronic clinical documentation. Scarcity of Attention, however, appeared to be a dominant key concept that intersected or overlapped with the other three emergent concepts
- SIGNIFICANT FINDING: ATTENTION AS A COMMODITY: HOW RELIANCE ON AUTOMATED TECHNOLOGY INFLUENCES How many of you have seen or heard any one of these safety warnings pop up in your vehicle? What about on a website? How many of you have “initially” ignored or shut off the any of these automated warnings or lights because of the annoying popups? Or because you thought it was just to bring your vehicle in for routine maintenance? (Make connection to automated EHR safety warnings and alert fatigue)
- The 5-rights policy is a safeguard for medication administration in which five things must be confirmed: right patient, right time, right dose, right route, and right medication. Dr. Bolls Chapter Psychophysiology in the context of media processes and effects research Book: Psychophysiological Measurement and Meaning: … (Kindle Edition) 5 Rights: the right patient the right drug the right dose the right route the right time UCSF 70 ICU AHRQ 66 ICU care beds Citation: Bob Wachter, MD Alert fatigue increases with growing exposure to alerts and heavier use of CPOE systems. This finding is intuitive, but also raises the important implication that without system redesign, the safety consequences of alert fatigue will likely become more serious over time. m Chairman of the Department of Medicine at the University of California, San Francisco (UCSF) Aug. 2015. IHI.org
- Attention Structures are metaphoric means of narrative expression that influence human attention to verbal/nonverbal cues e.g. Buttons, Icons, Codes….. Coding of visuals - the coding depends on “what appears” as well as “how it was designed to present content” (212). The visuals correlate with the T-unit of analysis in that it identifies the relationship between the clinician (people), thing (EHR template), and action (task performance).”
- All three methods of inquiry reveal that scarcity of attention in relationship to automated technology was a leading cause of transaction hazards in electronic clinical documentation. Scarcity of attention is influenced by three main factors task performance, EHR functionality, and fragmented narrative. One significant finding is how attention structures such as automated technology (visual and textual cues) in the electronic medical record or template contribute transaction hazards in the EHR-generated narrative during the clinical documentation process. Attention Structures: How we pay attention to the world of [digital] information and hence what use we can make of it. (Lanham 14)
- All three methods of inquiry reveal that scarcity of attention in relationship to automated technology was a leading cause of transaction hazards in electronic clinical documentation. Scarcity of attention is influenced by three main factors task performance, EHR functionality, and fragmented narrative. One significant finding is how attention structures such as automated technology (visual and textual cues) in the electronic medical record or template contribute transaction hazards in the EHR-generated narrative during the clinical documentation process. Attention Structures: How we pay attention to the world of [digital] information and hence what use we can make of it. (Lanham 14)
- All three methods of inquiry reveal that scarcity of attention in relationship to automated technology was a leading cause of transaction hazards in electronic clinical documentation. Scarcity of attention is influenced by three main factors task performance, EHR functionality, and fragmented narrative. One significant finding is how attention structures such as automated technology (visual and textual cues) in the electronic medical record or template contribute transaction hazards in the EHR-generated narrative during the clinical documentation process. Attention Structures: How we pay attention to the world of [digital] information and hence what use we can make of it. (Lanham 14)
- Conclusions and Next Steps (Slide 11) In this slide, you can suggest that more work is needed in this domain. Perhaps there are some remaining aspects of the research question that you couldn’t quite get to, or something about your sampling strategy that might have biased the outcomes. Perhaps your conclusions lead inexorably to more questions, and you could identify some of these … especially if your intention is to go on with this or if you want to influence the trajectory of other researchers in the room. This penultimate slide allows you to answer the big-picture question, and it should summarize the takeaway ideas that will interest even people who don’t care about your particular case study. They can be simply stated, but like your slide of research questions, they will take a lot of drafting and redrafting. Indeed, you may rephrase your conclusions the night before a presentation, to highlight conclusions you expect your audience will be particularly interested in. This is where you can say big things about the intellectual merit or broad impact of your work. What are takeaway ideas one, two and three?
- Recommended Assessment Models 3D Model in Applied Rhetoric (Carter) Looks at the EHR from text production to consumption within society. i.e. 1. How EHR vendors develop text and technology, and then how the EHR as a rhetorical product compete for providers’ attention. 2. How the EHR’s text and technology compete for users attention during the documentation process. 8D Sociotechnical Systems Model for HIT (Sittig and Singh)
- References (Slide 12) This isn’t about referencing other people’s work, it is about your work and it should identify some of the writing you’ve done in this domain. It doesn’t only have to list published items, it can list working papers, co-authored articles or manuscripts that are forthcoming, under review or in preparation. It is great if you have an authored or co-authored piece on the topic you are presenting on. But when most of us are presenting new research it hasn’t come out in print, so as long as your references are relevant to the research they should be identified here. If you haven’t actually published, then perhaps list your team members and move the funder information from the early slide to this slide. Repeat your identifying information from the first slide, and then list two or three items or the URL of a website where people could find out more about your work. This slide can stay up during the question and answer period, and it is much better than a final slide that says “good-bye,” “thank you” or worse, “fin.”
- In the medical industry, automated alerts and menu types are contributing factors as to why transaction hazards occur in EHR-generated narratives. Making assumptions that the technology will do the work (writing) for the clinician is an issue that came up with all three methods of inquiry. Observation: If the color is incorrectly cued or not cued at all, clinicians tend to ignore of chart by exception even if the diagnosis or procedure falls outside the norm e.g. communication type menus Interviews: Alert Fatigue and Charting by Exception: Too many pop ups, oftentimes for routine system maintenance, are ignored because of frequency or irrelevancy to the task at hand. Clinicians assume technology is correct and may ignore “free text” as an option. Organization of content difficult to find information or information is not linear Survey: Incomplete or incorrect documentation. Not paying attention to what is documented or not documented in the narrative. Can affect the rhetorical value and integrity of the narrative.
- PURPOSE: Explore end-user perspectives regarding EHR clinical documentation practices that enable or disable EHR narrative constructs. How scarcity of human attention affects EHR clinical documentation practices that affect the integrity of the clinical narrative due to digital information overload (Heifferon and Brown 2008) The rhetoric of healthcare and medicine focuses on the social, legal, and ethical aspects of how medical information or text is transmitted, interpreted, and received. ” which requires a closer examination of “medically-based rhetorical communication” (2). Heifferon and Brown see the rhetoric of health and medicine as “a persuasive form of healthcare discourse” (4). Judy Segal (2005) similarly approaches the rhetoric of medicine as a study of persuasion, noting how rhetoric “is a central element in many medical situations” (Loc. 38). Segal’s rhetorical study of health and medicine specifically sought to find out about “strategies that influence medical authorship” including decision-making practices regarding illness narratives (Loc. 48). In more recent years, most research in the rhetoric of health and medicine has shifted toward the study of eHealth communication, specifically the relationships among human interaction, computer literacy, and digital text content in medical discourses According to Balka and Butt (2008) eHealth “covers a wide range of socio-technical innovations in health service delivery and organization” to include electronic health records. In their argument about eHealth information, The, complicating circumstances with eHealth communication and information exchange include “the motivation of the information producer, or the mediating roles that computer hardware and software may play in the process of information exchange (79). One example of a complicating circumstance is how computer illiteracy contributes to accessibility barriers that can influence how users interact and communicate “important health information and messages” (585). Balka and Butt emphasize the strength of the “rhetoric of empowerment surrounding the introduction of internet-based health information” (79). One argument that Balka and Butt make about
- Too observe hat types of communication challenges the visual and textual content presented to the participant. understand what Potter and Levine-Donnerstein (1999) describe as “shift[ing] the focus to the meaning underlying the elements on the surface of a message” (259). In the coding of latent content, Blythe states that the coding process “requires a sensitivity to context and the ability to understand the purpose, audience, and other factors that motivate any statement” (215). By adapting Blythe’s coding techniques, I was able to identify how metaphoric expressions represent the meaning of the clinical narrative. Attention Structures : Verbal or non verbal signals (i.e. text, image, or sound) as a means of expression - Signals as metaphoric expressions of clinical narrative
- In the medical industry, automated alerts and menu types are contributing factors as to why transaction hazards occur in EHR-generated narratives. In the medical industry, automated alerts and menu types are contributing factors as to why transaction hazards occur in EHR-generated narratives. In my contextual rhetorical analysis and interview findings it was noted that many clinicians rely on automated text and technology to document information. In other words, they go through the motions by not paying close attention to a limited choice of information presented. If the clinicians are in a hurry and do not understand or pay attention to the functionality of EHR technology, how it works within the process of documenting patient information, critical patient information may not get documented due to a lack of attention to detail in the narrative. This finding is again directed to clinicians not paying attention to the necessary, additional narrative details when documenting patient information. Based on my research findings, clinicians’ lack of understanding about the functionality of EHR technology is evident with how they respond to automated safety alerts and popup menus. This type of automated technology also represents a type of attention structure that encourages alert fatigue – “the near-constant, often-annoying profusion of system alerts” as audio and visual warnings that pop up in the screen.”
- While the navigation menu allows users to toggle back and forth, additional challenges arise with the constant presence of numerous dropdown alerts and menus, which disrupt the attention and flow of the clinical documentation process. In other words, clinicians may just go through the motions or steps without paying attention to the abundant alerts or even guessing at selections in the default dropdowns without highlighted flags or “emergency exit” warnings. These types of issues were most evident during the task performance, which was flagged during the coding of “Verbal Concerns.” (next slide shows example from task performance)
- Number of times safety alerts popped up during the 30 minute EHR testing event.
- No Physician Participation The role and accountability of physicians as documentation specialists is significant in the integrity of EHR-generated narratives. However, without documented perspectives from physicians it is difficult to assess how and why physicians feel challenged with the EHR technology. Off-the record? No problem sharing. Observation at Point of Care not possible To observe fist-hand how clinicians navigate through the EHR and where challenges appear at point-of-care. Lack of direct communication with EHR vendors Limited Survey Population Small number of survey participants who volunteered for the study. Although my target audience was a purposeful sample, including members from two private health finance and CDI organizations, I believe a larger response pool would have provided a more accurate national consensus of how health professionals perceived EHR system management and suggestions for best practices in clinical documentation.