Do You Know What Your Scribe Did Last Spring? The Impact of COVID-19 on Medical Scribe Workflow

Objective  To understand the impact of the shift to virtual medicine induced by coronavirus disease 2019 (COVID-19) has had on the workflow of medical scribes. Design  This is a prospective observational survey-based study. Setting  This study was conducted at academic medical center in the United States. Participants  Seventy-four scribes working in ambulatory practices within an academic medical center. Interventions  All medical scribes received a survey assessing their workflow since beginning of COVID-19 restrictions. Primary and Secondary Outcomes  To assess the current workflow of medical scribes since transition to virtual care. Secondary outcomes are to assess the equipment used and location of their new workflow. Results  Fifty-seven scribes completed the survey. Overall 42% of scribes have transitioned to remote scribing with 97% serving as remote scribes for remote visits. This workflow is conducted at home and with personal equipment. Of those not working as scribes, 46% serve in preclinic support, with a wide range of EHR-related activities being reported. The remaining scribes have been either redeployed or furloughed. Conclusion  The rapid transition to virtual care brought about by COVID-19 has resulted in a dramatic shift in scribe workflow with the adoption of a previously unreported workflow of remote scribing for virtual care. Additional work is now needed to ensure these new workflows are safe and effective and that scribes are trained to work in this new paradigm.     

Implementing an Application Programming Interface for PROMIS Measures at Three Medical Centers

Background  There is an increasing body of literature advocating for the collection of patient-reported outcomes (PROs) in clinical care. Unfortunately, there are many barriers to integrating PRO measures, particularly computer adaptive tests (CATs), within electronic health records (EHRs), thereby limiting access to advances in PRO measures in clinical care settings. Objective  To address this obstacle, we created and evaluated a software integration of an Application Programming Interface (API) service for administering and scoring Patient-Reported Outcomes Measurement Information System (PROMIS) measures with the EHR system. Methods  We created a RESTful API and evaluated the technical feasibility and impact on clinical workflow at three academic medical centers. Results  Collaborative teams (i.e., clinical, information technology [IT] and administrative staff) performed these integration efforts addressing issues such as software integration as well as impact on clinical workflow. All centers considered their implementation successful based on the high rate of completed PROMIS assessments (between January 2016 and January 2021) and minimal workflow disruptions. Conclusion  These case studies demonstrate not only the feasibility but also the pathway for the integration of PROMIS CATs into the EHR and routine clinical care. All sites utilized diverse teams with support and commitment from institutional leadership, initial implementation in a single clinic, a process for monitoring and optimization, and use of custom software to minimize staff burden and error.     

A Mobile,Electronic Health Record-Connected Application for Managing Team Workflows in Inpatient Care

Background  Clinical workflows require the ability to synthesize and act on existing and emerging patient information. While offering multiple benefits, in many circumstances electronic health records (EHRs) do not adequately support these needs. Objectives  We sought to design, build, and implement an EHR-connected rounding and handoff tool with real-time data that supports care plan organization and team-based care. This article first describes our process, from ideation and development through implementation; and second, the research findings of objective use, efficacy, and efficiency, along with qualitative assessments of user experience. Methods  Guided by user-centered design and Agile development methodologies, our interdisciplinary team designed and built Carelign as a responsive web application, accessible from any mobile or desktop device, that gathers and integrates data from a health care institution''s information systems. Implementation and iterative improvements spanned January to July 2016. We assessed acceptance via usage metrics, user observations, time–motion studies, and user surveys. Results  By July 2016, Carelign was implemented on 152 of 169 total inpatient services across three hospitals staffing 1,616 hospital beds. Acceptance was near-immediate: in July 2016, 3,275 average unique weekly users generated 26,981 average weekly access sessions; these metrics remained steady over the following 4 years. In 2016 and 2018 surveys, users positively rated Carelign''s workflow integration, support of clinical activities, and overall impact on work life. Conclusion  User-focused design, multidisciplinary development teams, and rapid iteration enabled creation, adoption, and sustained use of a patient-centered digital workflow tool that supports diverse users'' and teams'' evolving care plan organization needs.     

Toward a Learning Health Care System: A Systematic Review and Evidence-Based Conceptual Framework for Implementation of Clinical Analytics in a Digital Hospital

Objective  A learning health care system (LHS) uses routinely collected data to continuously monitor and improve health care outcomes. Little is reported on the challenges and methods used to implement the analytics underpinning an LHS. Our aim was to systematically review the literature for reports of real-time clinical analytics implementation in digital hospitals and to use these findings to synthesize a conceptual framework for LHS implementation. Methods  Embase, PubMed, and Web of Science databases were searched for clinical analytics derived from electronic health records in adult inpatient and emergency department settings between 2015 and 2021. Evidence was coded from the final study selection that related to (1) dashboard implementation challenges, (2) methods to overcome implementation challenges, and (3) dashboard assessment and impact. The evidences obtained, together with evidence extracted from relevant prior reviews, were mapped to an existing digital health transformation model to derive a conceptual framework for LHS analytics implementation. Results  A total of 238 candidate articles were reviewed and 14 met inclusion criteria. From the selected studies, we extracted 37 implementation challenges and 64 methods employed to overcome such challenges. We identified common approaches for evaluating the implementation of clinical dashboards. Six studies assessed clinical process outcomes and only four studies evaluated patient health outcomes. A conceptual framework for implementing the analytics of an LHS was developed. Conclusion  Health care organizations face diverse challenges when trying to implement real-time data analytics. These challenges have shifted over the past decade. While prior reviews identified fundamental information problems, such as data size and complexity, our review uncovered more postpilot challenges, such as supporting diverse users, workflows, and user-interface screens. Our review identified practical methods to overcome these challenges which have been incorporated into a conceptual framework. It is hoped this framework will support health care organizations deploying near-real-time clinical dashboards and progress toward an LHS.     

Ambulatory Clinician's Guide to Inpatient Service: An Innovative Rapid Onboarding Strategy for the COVID-19 Pandemic

Background and Significance  When hospitals are subject to prolonged surges in patients, such as during the coronavirus disease 2019 (COVID-19) pandemic, additional clinicians may be needed to care for the rapid increase of acutely ill patients. How might we quickly prepare a large number of ambulatory-based clinicians to care for hospitalized patients using the inpatient workflow of the electronic health record (EHR)? Objectives  The aim of the study is to create a successful training intervention which prepares ambulatory-based clinicians as they transition to inpatient services. Methods  We created a training guide with embedded videos that describes the workflow of an inpatient clinician. We delivered this intervention via an e-mail hyperlink, a static hyperlink inside of the EHR, and an on-demand hyperlink within the EHR. Results  In anticipation of the first peak of inpatients with COVID-19 in April 2020, the training manual was accessed 261 times by 167 unique users as clinicians anticipated being called into service. As our institution has not yet needed to deploy ambulatory-based clinicians for inpatient service, usage data of the training document is still pending. Conclusion  We intend that our novel implementation of a multimedia, highly accessible onboarding document with access from points inside and outside of the EHR will improve clinician performance and serve as a helpful example to other organizations during the COVID-19 pandemic and beyond.     

Interaction Time with Electronic Health Records: A Systematic Review

Background  The amount of time that health care clinicians (physicians and nurses) spend interacting with the electronic health record is not well understood. Objective  This study aimed to evaluate the time that health care providers spend interacting with electronic health records (EHR). Methods  Data are retrieved from Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily, (Ovid) Embase, CINAHL, and SCOPUS. Study Eligibility Criteria  Peer-reviewed studies that describe the use of EHR and include measurement of time either in hours, minutes, or in the percentage of a clinician''s workday. Papers were written in English and published between 1990 and 2021. Participants  All physicians and nurses involved in inpatient and outpatient settings. Study Appraisal and Synthesis Methods  A narrative synthesis of the results, providing summaries of interaction time with EHR. The studies were rated according to Quality Assessment Tool for Studies with Diverse Designs. Results  Out of 5,133 de-duplicated references identified through database searching, 18 met inclusion criteria. Most were time-motion studies (50%) that followed by logged-based analysis (44%). Most were conducted in the United States (94%) and examined a clinician workflow in the inpatient settings (83%). The average time was nearly 37% of time of their workday by physicians in both inpatient and outpatient settings and 22% of the workday by nurses in inpatient settings. The studies showed methodological heterogeneity. Conclusion  This systematic review evaluates the time that health care providers spend interacting with EHR. Interaction time with EHR varies depending on clinicians'' roles and clinical settings, computer systems, and users'' experience. The average time spent by physicians on EHR exceeded one-third of their workday. The finding is a possible indicator that the EHR has room for usability, functionality improvement, and workflow optimization.     

Moving Faster than the COVID-19 Pandemic: The Rapid,Digital Transformation of a Public Health System

Background  Queensland, Australia has been successful in containing the COVID-19 pandemic. Underpinning that response has been a highly effective virus containment strategy which relies on identification, isolation, and contact tracing of cases. The dramatic emergence of the COVID-19 pandemic rendered traditional paper-based systems for managing contact tracing no longer fit for purpose. A rapid digital transformation of the public health contact tracing system occurred to support this effort. Objectives  The objectives of the digital transformation were to shift legacy systems (paper or standalone electronic systems) to a digitally enabled public health system, where data are centered around the consumer rather than isolated databases. The objective of this paper is to outline this case study and detail the lessons learnt to inform and give confidence to others contemplating digitization of public health systems in response to the COVID-19 pandemic. Methods  This case study is set in Queensland, Australia. Universal health care is available. A multidisciplinary team was established consisting of clinical informaticians, developers, data strategists, and health information managers. An agile “pair-programming” approach was undertaken to application development and extensive change efforts were made to maximize adoption of the new digital workflows. Data governance and flows were changed to support rapid management of the pandemic. Results  The digital coronavirus application (DCOVA) is a web-based application that securely captures information about people required to quarantine and creates a multiagency secure database to support a successful containment strategy. Conclusion  Most of the literature surrounding digital transformation allows time for significant consultation, which was simply not possible under crisis conditions. Our observation is that staff was willing to adopt new digital systems because the reason for change (the COVID-19 pandemic) was clearly pressing. This case study highlights just how critical a unified purpose, is to successful, rapid digital transformation.     

Improving COVID-19 Research of University Hospitals in Germany: Formative Usability Evaluation of the CODEX Feasibility Portal

Background  Within the German “Network University Medicine,” a portal is to be developed to enable researchers to query on novel coronavirus disease 2019 (COVID-19) data from university hospitals for assessing the feasibility of a clinical study. Objectives  The usability of a prototype for federated feasibility queries was evaluated to identify design strengths and weaknesses and derive improvement recommendations for further development. Methods  In the course of a remote usability test with the thinking-aloud method and posttask interviews, 15 clinical researchers evaluated the usability of a prototype of the Feasibility Portal. The identified usability problems were rated according to severity, and improvement recommendations were derived. Results  The design of the prototype was rated as simple, intuitive, and as usable with little effort. The usability test reported a total of 26 problems, 8 of these were rated as “critical.” Usability problems and revision recommendations focus primarily on improving the visual distinguishability of selected inclusion and exclusion criteria, enabling a flexible approach to criteria linking, and enhancing the free-text search. Conclusion  Improvement proposals were developed for these user problems which will guide further development and the adaptation of the portal to user needs. This is an important prerequisite for correct and efficient use in everyday clinical work in the future. Results can provide developers of similar systems with a good starting point for interface conceptualizations. The methodological approach/the developed test guideline can serve as a template for similar evaluations.     

Opportunities and Challenges of Telehealth in Disease Management during COVID-19 Pandemic: A Scoping Review

Objective  The novel coronavirus disease 2019 (COVID-19) pandemic is an unexpected universal problem that has changed health care access across the world. Telehealth is an effective solution for health care delivery during disasters and public health emergencies. This study was conducted to summarize the opportunities and challenges of using telehealth in health care delivery during the COVID-19 pandemic. Methods  A structured search was performed in the Web of Science, PubMed, Science Direct, and Scopus databases, as well as the Google Scholar search engine, for studies published until November 4, 2020. The reviewers analyzed 112 studies and identified opportunities and challenges. This review followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) protocols. Quality appraisal was done according to the Mixed Methods Appraisal Tool (MMAT) version 2018. Thematic analysis was applied for data analysis. Results  A total of 112 unique opportunities of telehealth application during the pandemic were categorized into 4 key themes, such as (1) clinical, (2) organizational, (3) technical, and (4) social, which were further divided into 11 initial themes and 26 unique concepts. Furthermore, 106 unique challenges were categorized into 6 key themes, such as (1) legal, (2) clinical, (3) organizational, (40 technical, (5) socioeconomic, and (6) data quality, which were divided into 16 initial themes and 37 unique concepts altogether. The clinical opportunities and legal challenges were the most frequent opportunities and challenges, respectively. Conclusion  The COVID-19 pandemic significantly accelerated the use of telehealth. This study could offer useful information to policymakers about the opportunities and challenges of implementing telehealth for providing accessible, safe, and efficient health care delivery to the patient population during and after COVID-19. Furthermore, it can assist policymakers to make informed decisions on implementing telehealth in response to the COVID-19 pandemic by addressing the obstacles ahead.     

Identifying Opportunities for Workflow Automation in Health Care: Lessons Learned from Other Industries

Background  Workflow automation, which involves identifying sequences of tasks that can be streamlined by using technology and modern computing, offers opportunities to address the United States health care system''s challenges with quality, safety, and efficiency. Other industries have successfully implemented workflow automation to address these concerns, and lessons learned from those experiences may inform its application in health care. Objective  Our aim was to identify and synthesize (1) current approaches in workflow automation across industries, (2) opportunities for applying workflow automation in health care, and (3) considerations for designing and implementing workflow automation that may be relevant to health care. Methods  We conducted a targeted review of peer-reviewed and gray literature on automation approaches. We identified relevant databases and terms to conduct the searches across sources and reviewed abstracts to identify 123 relevant articles across 11 disciplines. Results  Workflow automation is used across industries such as finance, manufacturing, and travel to increase efficiency, productivity, and quality. We found automation ranged from low to full automation, and this variation was associated with task and technology characteristics. The level of automation is linked to how well a task is defined, whether a task is repetitive, the degree of human intervention and decision-making required, and the sophistication of available technology. We found that identifying automation goals and assessing whether those goals were reached was critical, and ongoing monitoring and improvement would help to ensure successful automation. Conclusion  Use of workflow automation in other industries can inform automating health care workflows by considering the critical role of people, process, and technology in design, testing, implementation, use, and ongoing monitoring of automated workflows. Insights gained from other industries will inform an interdisciplinary effort by the Office of the National Coordinator for Health Information Technology to outline priorities for advancing health care workflow automation.     

Defining Data Migration Across Multidisciplinary Ambulatory Clinics Using Participatory Design

Objective  This study aimed to develop an institutional approach for defining data migration based on participatory design principles. Methods  We outline a collaborative approach to define data migration as part of an electronic health record (EHR) transition at an urban hospital with 20 ambulatory clinics, based on participatory design. We developed an institution-specific list of data for migration based on physician end-user feedback. In this paper, we review the project planning phases, multidisciplinary governance, and methods used. Results  Detailed data migration feedback was obtained from 90% of participants. Depending on the specialty, requests for historical laboratory values ranged from 2 to as many as 145 unique laboratory types. Lookback periods requested by physicians varied and were ultimately assigned to provide the most clinical data. This clinical information was then combined to synthesize an overall proposed data migration request on behalf of the institution. Conclusion  Institutions undergoing an EHR transition should actively involve physician end-users and key stakeholders. Physician feedback is vital for developing a clinically relevant EHR environment but is often difficult to obtain. Challenges include physician time constraints and overall knowledge about health information technology. This study demonstrates how a participatory design can serve to improve the clinical end-user''s understanding of the technical aspects of an EHR implementation, as well as enhance the outcomes of such projects.     

A Framework for Systematic Assessment of Clinical Trial Population Representativeness Using Electronic Health Records Data

Background  Clinical trials are the gold standard for generating robust medical evidence, but clinical trial results often raise generalizability concerns, which can be attributed to the lack of population representativeness. The electronic health records (EHRs) data are useful for estimating the population representativeness of clinical trial study population. Objectives  This research aims to estimate the population representativeness of clinical trials systematically using EHR data during the early design stage. Methods  We present an end-to-end analytical framework for transforming free-text clinical trial eligibility criteria into executable database queries conformant with the Observational Medical Outcomes Partnership Common Data Model and for systematically quantifying the population representativeness for each clinical trial. Results  We calculated the population representativeness of 782 novel coronavirus disease 2019 (COVID-19) trials and 3,827 type 2 diabetes mellitus (T2DM) trials in the United States respectively using this framework. With the use of overly restrictive eligibility criteria, 85.7% of the COVID-19 trials and 30.1% of T2DM trials had poor population representativeness. Conclusion  This research demonstrates the potential of using the EHR data to assess the clinical trials population representativeness, providing data-driven metrics to inform the selection and optimization of eligibility criteria.     

Shared-Task Worklists Improve Clinical Trial Recruitment Workflow in an Academic Emergency Department

Background  Clinical trials performed in our emergency department at Barnes-Jewish Hospital utilize a centralized infrastructure for alerting, screening, and enrollment with rule-based alerts sent to clinical research coordinators. Previously, all alerts were delivered as text messages via dedicated cellular phones. As the number of ongoing clinical trials increased, the volume of alerts grew to an unmanageable level. Therefore, we have changed our primary notification delivery method to study-specific, shared-task worklists integrated with our pre-existing web-based screening documentation system. Objective  To evaluate the effects on screening and recruitment workflow of replacing text-message delivery of clinical trial alerts with study-specific shared-task worklists in a high-volume academic emergency department supporting multiple concurrent clinical trials. Methods  We analyzed retrospective data on alerting, screening, and enrollment for 10 active clinical trials pre- and postimplementation of shared-task worklists. Results  Notifications signaling the presence of potentially eligible subjects for clinical trials were more likely to result in a screen ( p  < 0.001) with the implementation of shared-task worklists compared with notifications delivered as text messages for 8/10 clinical trials. The change in workflow did not alter the likelihood of a notification resulting in an enrollment ( p  = 0.473). The Director of Research reported a substantial reduction in the amount of time spent redirecting clinical research coordinator screening activities. Conclusion  Shared-task worklists, with the functionalities we have described, offer a viable alternative to delivery of clinical trial alerts via text message directly to clinical research coordinators recruiting for multiple concurrent clinical trials in a high-volume academic emergency department.     

Workflow Automation for a Virtual Hypertension Management Program

Objectives  Hypertension is a modifiable risk factor for numerous comorbidities and treating hypertension can greatly improve health outcomes. We sought to increase the efficiency of a virtual hypertension management program through workflow automation processes. Methods  We developed a customer relationship management (CRM) solution at our institution for the purpose of improving processes and workflow for a virtual hypertension management program and describe here the development, implementation, and initial experience of this CRM system. Results  Notable system features include task automation, patient data capture, multi-channel communication, integration with our electronic health record (EHR), and device integration (for blood pressure cuffs). In the five stages of our program (intake and eligibility screening, enrollment, device configuration/setup, medication titration, and maintenance), we describe some of the key process improvements and workflow automations that are enabled using our CRM platform, like automatic reminders to capture blood pressure data and present these data to our clinical team when ready for clinical decision making. We also describe key limitations of CRM, like balancing out-of-the-box functionality with development flexibility. Among our first group of referred patients, 76% (39/51) preferred email as their communication method, 26/51 (51%) were able to enroll electronically, and 63% of those enrolled (32/51) were able to transmit blood pressure data without phone support. Conclusion  A CRM platform could improve clinical processes through multiple pathways, including workflow automation, multi-channel communication, and device integration. Future work will examine the operational improvements of this health information technology solution as well as assess clinical outcomes.     

Health Intelligence Atlas: A Core Tool for Public Health Intelligence

Background  The dramatic increase in complexity and volume of health data has challenged traditional health systems to deliver useful information to their users. The novel coronavirus disease 2019 (COVID-19) pandemic has further exacerbated this problem and demonstrated the critical need for the 21st century approach. This approach needs to ingest relevant, diverse data sources, analyze them, and generate appropriate health intelligence products that enable users to take more effective and efficient actions for their specific challenges. Objectives  This article characterizes the Health Intelligence Atlas (HI-Atlas) development and implementation to produce Public Health Intelligence (PHI) that supports identifying and prioritizing high-risk communities by public health authorities. The HI-Atlas moves from post hoc observations to a proactive model-based approach for preplanning COVID-19 vaccine preparedness, distribution, and assessing the effectiveness of those plans. Results  Details are presented on how the HI-Atlas merged traditional surveillance data with social intelligence multidimensional data streams to produce the next level of health intelligence. Two-model use cases in a large county demonstrate how the HI-Atlas produced relevant PHI to inform public health decision makers to (1) support identification and prioritization of vulnerable communities at risk for COVID-19 spread and vaccine hesitancy, and (2) support the implementation of a generic model for planning equitable COVID-19 vaccine preparedness and distribution. Conclusion  The scalable models of data sources, analyses, and smart hybrid data layer visualizations implemented in the HI-Atlas are the Health Intelligence tools designed to support real-time proactive planning and monitoring for COVID-19 vaccine preparedness and distribution in counties and states.     

Rapid Implementation of a Complex,Multimodal Technology Response to COVID-19 at an Integrated Community-Based Health Care System

Background  The rapid spread of severe acute respiratory syndrome coronavirus-2 or SARS-CoV-2 necessitated a scaled treatment response to the novel coronavirus disease 2019 (COVID-19). Objective  This study aimed to characterize the design and rapid implementation of a complex, multimodal, technology response to COVID-19 led by the Intermountain Healthcare''s (Intermountain''s) Care Transformation Information Systems (CTIS) organization to build pandemic surge capacity. Methods  Intermountain has active community-spread cases of COVID-19 that are increasing. We used the Centers for Disease Control and Prevention Pandemic Intervals Framework (the Framework) to characterize CTIS leadership''s multimodal technology response to COVID-19 at Intermountain. We provide results on implementation feasibility and sustainability of health information technology (HIT) interventions as of June 30, 2020, characterize lessons learned and identify persistent barriers to sustained deployment. Results  We characterize the CTIS organization''s multimodal technology response to COVID-19 in five relevant areas of the Framework enabling (1) incident management, (2) surveillance, (3) laboratory testing, (4) community mitigation, and (5) medical care and countermeasures. We are seeing increased use of traditionally slow-to-adopt technologies that create additional surge capacity while sustaining patient safety and care quality. CTIS leadership recognized early that a multimodal technology intervention could enable additional surge capacity for health care delivery systems with a broad geographic and service scope. A statewide central tracking system to coordinate capacity planning and management response is needed. Order interoperability between health care systems remains a barrier to an integrated response. Conclusion  The rate of future pandemics is estimated to increase. The pandemic response of health care systems, like Intermountain, offers a blueprint for the leadership role that HIT organizations can play in mainstream care delivery, enabling a nimbler, virtual health care delivery system that is more responsive to current and future needs.     

Multidisciplinary Sprint Program Achieved Specialty-Specific EHR Optimization in 20 Clinics

Objective  The objective of the study was to highlight and analyze the outcomes of software configuration requests received from Sprint, a comprehensive, clinic-centered electronic health record (EHR) optimization program. Methods  A retrospective review of 1,254 Sprint workbook requests identified (1) the responsible EHR team, (2) the clinical efficiency gained from the request, and (3) the EHR intervention conducted. Results  Requests were received from 407 clinicians and 538 staff over 31 weeks of Sprint. Sixty-nine percent of the requests were completed during the Sprint. Of all requests, 25% required net new build, 73% required technical investigation and/or solutions, and 2% of the requests were escalated to the vendor. The clinical specialty groups requested a higher percentage of items that earned them clinical review (16 vs. 10%) and documentation (29 vs. 23%) efficiencies compared with their primary care colleagues who requested slightly more order modifications (22 vs. 20%). Clinical efficiencies most commonly associated with workbook requests included documentation (28%), ordering (20%), in basket (17%), and clinical review (15%). Sprint user requests evaluated by ambulatory, hardware, security, and training teams comprised 80% of reported items. Discussion  Sprint requests were categorized as clean-up, break-fix, workflow investigation, or new build. On-site collaboration with clinical care teams permitted consensus-building, drove vetting, and iteration of EHR build, and led to goal-driven, usable workflows and EHR products. Conclusion  This program evaluation demonstrates the process by which optimization can occur and the products that result when we adhere to optimization principles in health care organizations.