In a Manner of Speaking…..

Transatlantic Connections Medical Humanities Bundoran, Ireland | January 11, 2017

The Rhetoric and Economics of User Attention in the Study of eHealth Clinical Narrative Construction

Susan Rauch, Ph.D

Slideshare.net: Rauch Transatlantic

EHEALTH NARRATIVE RESEARCH:Why Rhetoric and Economics of Attention? Understand the rhetorical and communicative 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 including the stabilizing and destabilizing forces e.g. attention that enable or disable the EHR narrative constructs

RESEARCH DESIGN

METHODS• Contextual-Rhetorical Analysis: EHR UX Testing Event:

Task Performance and Interface Design• Interviews: 36 health professionals, 2 hospitals• Survey: 42 responses from HFMA and ACDIS experts*

APPLIED THEORY AND ASSESSMENT MODELS• Economics of Attention (Richard Lanham)• 8D Sociotechnical Systems Model for HIT (Sittig and Singh)• 3D Model in Applied Rhetoric (Joyce Locke Carter)• 10 Heuristics for Usability Testing (Nielsen)

*HFMA: Health Finance Management Association Membership*CDIS: Association for Clinical Documentation Improvement Specialists Membership

WHEN THE DOCUMENT’s INTEGRITY AND VALUE OF EHR CLINICAL NARRATIVE IS COMPROMISED

ECONOMICS OF HUMAN ATTENTION: Identifying Transaction Hazards in EHR Clinical Documentation

ARE WE PAYING ATTENTION?

ALERT FATIGUE: What is it?

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).

AUTOMATED TEXT AND TECHNOLOGY: Attention to EHR Safety Alerts

UCSF Medical Center (Wachter 2015)•Physicians: 30,000 (just computerized pop-up boxes)•Pharmacists: 160,000•Computers (HR, BP, Ox monitors): 2.5 million

AHRQ 2014 Study ICU CPOE Monitors•2 million alerts=187 warnings/patient/day

Safety Alerts: 1 Month Frequency Stats

IHA WachterVideo

3. Rx Safety Alert

Images: CabellHuntingtonHospital

1. Communication Type Menu (Noted in Task Performance Results)

Image: Cerner Store

E

Computerized Pop Ups

2. Task Alert

AUTOMATED TEXT AND TECHNOLOGY: Attention to EHR Safety Alerts

AUTOMATED TEXT AND TECHNOLOGY:Attention Structures

Charting by Exception (CBE) When technology supersedes act of critical thinking. Recall: Cheating through the documentation process e.g.

repeating the use of Function keys

Communication Type: Dropdown Menu with pre-selected norms. Uses visual color cues to suggest answers. If incorrectly chosen, the narrative is compromised.

Interview Participant: The right “Communication Type” selection . . . determines the electronic routing.

Navigation Menus, Buttons, and Icons

Images: UMC Usability Test Plan

ATTENTION STRUCTURES ANDDIGITAL INFORMATION OVERLOAD

Images: Cerner Store

CLINICAL DOCUMENATION: OSCILLATION & KAIROTIC SHIFTS

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) ASSESSMENT (presentation of symptoms and prior treatment) PLAN (recommended treatment)

CLINICAL DOCUMENATION: OSCILLATION and KAIROTIC SHIFTS

Images: Hosp. B Usability Testi Plan

LetDoctorsBeDoctors

KEY RESEARCH FINDINGS

INTERVIEW RESPONSE TRENDS

TASK PERFORMANCE (Heuristic Evaluation)•“If the physician does not pay attention and chooses the wrong thing, the order is incorrect…That is going to be bad. If the physicians don’t know how to put it in, or the clinic doesn’t know to put it in, it’s going to be up to the nurses to try and call the physician for clarification, or do their best to guess.” (Nielsen Heuristic #5: Recognition Rather Than Recall)

SURVEY•“Nuances that need a human to validate that the codes are correct and coded to highest degree of specificity.” •“Cutting (copying) and pasting…inability to complete documentation in a timely manner’•Utilizing templates incorrectly and causing cloning issues.”•“Drop-down diagnoses . .problem identifying diagnoses [codes] no longer relevant. •“Automated coding not accurate . . Does not always pick up pertinent information.•“Humans need to check the entries still.”

INTERVIEWS•“That’s just not paying attention. They get so used to the computer doing it for them, that they kind of almost lose those critical thinking skills.” (P12B)

CONTEXUAL-RHETORICAL ANALYSIS:Key Findings – Task Performance

Image Source: AllScripts Maternity

Attention Structures: Verbal/nonverbal signals (means of expression) in the EHR narrative constructs

RECOMMENDATIONS AND FUTURE RESEARCH

Automated Technologies: What about wearables?

RECOMMENDATIONS FOR FUTURE RESEARCH

IMPROVED DIGITAL LITERACY: Academic EHR SIM Models for Workplace Point-of-Care Clinician Training

OBSERVATIONS UX TESTING: At point-of-care to evaluate scarcity of attention and rhetorical value of attention structures•Mouse tracking and usability software to screencast record clinicians EHR documentation task performance•Observe EHR Developers in Document Design/Style

ASSESSMENT TOOLS FOR EHR WORKFLOW •Assessment models (3D and 8D) to study strategies in economics of attention that influence medical authorship and eHealth documentation practices (see handout)•10 heuristics for evaluating interface design

Economics of Attention: Rhetorical approach to attention economics theory. Competition for human attention as a scarce commodity. How style in electronic documentation attracts or regulates attention. (Richard Lanham)

Rhetoric of Healthcare and Medicine: “Strategies that influence medical authorship” (Segal). “How we interpret and receive texts as rhetoric” (Heifferon and Brown).

Applied Rhetoric: Rhetorical and competitive value of electronic text. How technical communicators create value (Joyce Locke Carter)

Sociotechnical Systems: User challenges associated with HIT design that affects workflow. (Sittig and Singh)

RECOMMENDATIONS AND FUTURE RESEARCH:New Methods of Inquiry and Applied Theory in Medical Humanities and Narrative Medicine

Workflow Models for EHR Narrative Research

RECOMMENDATIONS AND FUTURE RESEARCH

8D Sociotechnical Model – Sittig And SinghMeasurement for Sociotechnical Challenges in HIT Systems

Hardware and SoftwareInfrastructure 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.

PeopleEveryone 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 RegulationsExternal 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

RECOMMENDATIONS: Workflow Models for Medical Humanities Research

Handout: http://www.slideshare.net/SusanRauch1/rauch-transatlantic-connections-med-humanities-handout

FINAL OVERVIEW: RECOMMENDATIONS AND FUTURE RESEARCH

THEORY AND PRACTICEDraw from other disciplines outside medical humanities (Segal, Scott, Kernanen; Schiavo)TRAINING INITIATIVES To improve EHR digital literacy and communication practicesTEXT & TECHNOLOGY: APPLIED 3D AND 8D ASSESSMENT MODELSAssess the competition of and user sociotechnical challenges with EHR decision-making processes (see handout on Slideshare).Evaluate rhetorical value of competitive attention structures e.g. automated technology, alert fatigue, coding structuresAssess rhetorical value of decision-making in development and distribution of EHR systems (production-reception-social circumstance)Data Exchange between provider-provider and hospital facilities (presently not universalized - proprietary)

?’s

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

REFERENCES