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Where are we? The United States is in a period of time currently known as the Information Age. Began with the internet in the 1970s where computers could be operated from other terminals for scientific and military advantage. -This was owned by the government until 1984 Not open for commercial use until the WWW was created in the 1990s, which was used for corporations to promote and sell their products. eMails became a more convenient form of communication between colleagues and friends. Soon, technology was available for everyone to use. By the end of the 90’s the world was fast wired Picture: International Connectivity in 1995: How the internet has connected the world in just 20 years. How does this impact healthcare?
The beginnings of EHR technology can be traced back to the late 1960s with many different efforts at streamlining the medical data entry process. The efforts over the next 50 years were fragmented and not successful until the early 2000s. The evolution of EHR’s has been rapidly increased since the passage of the HITECH Act of 2009, a part of the American Recovery and Reinvestment Act of 2009, which was passed to increase the adoption and meaningful use of healthcare information technology. The meaningful use EHR Incentive Program also was enacted to ensure that the money given to promote EHR adoption was used in a useful and beneficial way. According to the The American Health Information Management Association, there are four technological advancements that have assisted in the shift towards the implementation of EHR technology: -Mainframe computers: only available to large companies and corporations -Mini-computers and personal computers: smaller software that was more affordable -Internet: secure communication and data sharing -Microprocessors: hand-held technology: availability and efficiency of information So what and why? How does this benefit patients and physicians? How do EHRs improve our overall quality of healthcare?
In an effort to streamline the health care process and consolidate the vast amount of knowledge that advances in healthcare made us available to, online databases were created to help both patients and physicians manage their health in a simpler more efficient way. This was done through an Electronic Medical Record and a Personal Health Record -Electronic Medical Record: an online record of the encounter of a patient and a physician during an episode of patient care. -Unique to each practice or provider that makes it -Personal Health Record: medical record maintained by the patient -PHR contains any personal health documentation provided to them by their physician Point out that these two are not interoperable. One is managed by the provider while the other is managed by the consumer. There needed to be a system that overcame this interoperability barrier and united these two together in order to for both the patient and the provider to have a holistic view of an individuals health care. That’s when EHRs were created. -Electronic Health Records: a comprehensive view of an individuals health care that combines their EMR with their PHR -Point of care information: Having all information about a patient, such as previous health visits, current medication, allergies, previous surgeries, etc. all available at each visit to each practice. -Reduction of errors: Reduce paperwork that gets lost in filing as well as thats difficult to send from one practice to another -Interoperability: connecting patient information, client scheduling, lab results, billing information, pharmacies, etc. together to make each clinical visit more efficient and effective for the patient, physician, the payer, everyone involved.
As technology advances we must keep up. EHR’s help the healthcare system ‘catch up’ to everyday changes in technology to benefit both patients and physicians
According to a study done by Dr. Richard Holden in 2011, there are 5 main categories of facilitators/barriers to the implementation of EHRs in healthcare settings: -user attributes: barriers related to individual users -Learning: time, repetition, and effort… cost -Understanding: knowing how to navigate -system attributes: barriers related to the EHR system and the hardware and software supporting it -support from others: barriers related to support received from others -organizational support: barriers related to organizational factors such as management and compensation -environmental factors: barriers related to physical or social work environment But according to our research, the two biggest barriers are Usability and Workflow -Usability: which is the extent to which the record can accomplish a set of goals in the work domain and the extent to which a system can be used to perform necessary tasks -The barrier here comes when the users don’t know how to effectively and efficiently use the EHR so that it can’t accomplish goals or perform necessary tasks -Workflow: the systematic sequence or process through which a piece of work passes from initiation to completion -The barrier here comes when the transition from paper charts to EHRs changes the way that a practice runs its daily organization. But studies show that the benefits of EHRs, when used correctly, far outway the costs that it take to implement them into a system. That’s why the National Center for Cognitive Informatics and Decision Making in Healthcare created a framework to help assess, and hopefully amend some of these burdens. This framework is called TURF.
So what is TURF? Turf stands for Task, user, representation, and function It’s an integrated toolkit for usability evaluation, testing, measurement, and design of EHRs. Turf has been developed by the SHARPC research group dedicated to addressing the usability and workflow challenges of Health Information Technology. We believe that TURF is the best way to overcome the barriers to EHR implementation. Our project evaluated the two primary functions of TURF: -to evaluate the usability of already existing electronic health records -to provide a framework for designing new and better electronic health records
TURF focuses on redesigning how EHR’s work to make them most effective. TURF isn’t about making the user fit the EHR, it’s about making the EHR fit the user and their needs How does it do this? Task – In evaluation, it’s important to make a detailed analysis of each step in using an EHR, both the physical and the mental tasks. For one thing, a task analysis is critical for figuring out which screen representation is best for each task. User – This is where it all starts in TURF, understanding the human being who interacts with the software and the machine. Representation – Bottom line, this means the EHR’s user interface. Developers expend so much effort representing the work domain on a computer screen, and users spend so much time interacting with this representation of their working world, that we consider this the essence of usability. Representation is “where the rubber meets the road”. Function – Analyzing the functions in the work domain, the basic structure of the work that the user and the system will perform together, is critical in improving usability of the system. Functions are key to the EHR’s usefulness.
How does TURF overcome the potential barriers to implementation?
Dr. Jiajie Zhang, the University of Texas Health Science Center at Houston’s National Center for Cognitive Informatics and Decision Making (NCCD) has developed several tools for measuring usability. Funding for the project comes from ONC’s Strategic Health IT Advanced Research initiative. They stated it was easy to adapt to, administration functions were a big plus
Usability can not only be defined under a coherent, unified theoretical framework, it can also be measured objectively and systematically. We presented a set of studies we did in the past to demonstrate how EHR usability could be evaluated and measured in a scientific and systematical way
TURF’s designers have created a system that not only tracks use, but also adds these major functions: User Sessions. TURF captures live screens, keystrokes, mouse clicks and can record a user’s verbal comments in an audio file. Administration. The tool is designed for testing by groups of users as well as individuals. It captures user demographics, consent forms, non disclosures, etc. All of these can be tailored. Testing for Specifics. TURF allows managers to test for specific problems. For example, you can see how users eprescribe, or create continuity of care documents. Comparing Steps. Managers can set up an optimum selection path or define the steps for a task and then compare these with user actions. Reporting. TURF builds in several counting and statistical analysis tools such as one way ANOVA. TURF can help explain what cognitive scientists call the “representation effect”, that is, how and why two different EHR’s can represent the same work domain so very differently. More to the point, TURF can point the way to the best representation for the task, the user and the function – the essence of usability.
EHR Implementation &
The TURF Framework for Usability
McKenzie Wilson, Kara Morris, Sarah Riley Saint, Jennifer Firmin
The Information Age
● Internet: 1970s
● World Wide Web: 1990s
● Electronic Mail
Evolution of EHR
● Early use: 1960s
o Many efforts to streamline medical data entry process
● HITECH Act: 2009
o American Recovery and Reinvestment Act: 2009
o Meaningful Use
● Technological Advancements
o Mainframe computers: large companies and corporations
o Mini-computers & personal computers: affordable
o Internet: secure communication and data sharing
o Microprocessors: hand-held technology, availability
Purpose of EHR
● Electronic Medical Record (EMR) & Personal Health
o Not interoperable: managed by provider and one by consumer
Multiple EMR & Unreliable PHR
● Electronic Health Record (EHR): comprehensive view of
an individual’s health care
o Point-of-care information
o Reduction of errors
Why do we need EHRs?
● Better Physician decisions and more coordinated care
Barriers to Implementation
● User attributes
● System attributes
● Support from others
● Organizational support
● Environmental factors
● **Usability: used to accomplish goals and extent to perform
● **Workflow: the systematic sequence or process through which a
piece of work passes from initiation to completion
What is TURF?
● Task, User, Representation, Function
● TURF is an integrated toolkit:
o Usability evaluation, testing, measurement, and
● Developed by SHARPC research group: addressing
usability and workflow
● Two primary functions:
o Evaluate usability of existing EHRs
o Provide framework for new EHRs
How does well TURF work?
“I found TURF to be a versatile, robust tool for EHR usability analysis. Its seeming
complexity masks an ability to work in various settings and tackle hosts of problems.
If you aren’t happy with your EHR’s interface, TURF gives a remarkable tool to
show what’s wrong and what you want. Indeed, with some adaptation you could use
TURF to analyze almost any program’s usability. Not bad for a freebie”
President, Silver Soft, Inc. Managing Partner, EHRSelector.com. Specializes in EMR/EHR systems
Why does TURF work?
● User Sessions
● Testing for Specifics
● Comparing Steps