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Copy-Forward in Electronic Health Records: Lipstick on a Pig
ARTICLE IN PRESS The Joint Commission Journal on Quality and Patient Safety 2017; ■■:■■–■■
Copy-Forward in Electronic Health Records: Lipstick on a Pig Linda Harrington, PhD, DNP, RN-BC
"P
utting lipstick on a pig” is a porcine proverb about how superficial changes, such as lipstick, are used in an attempt to disguise the true nature of something, as also reflected in the use of copy-forward functionality in the electronic health record (EHR). Copy-forward is a form of electronic documentation that allows EHR users to copy past electronic documentation forward to a current location without retyping it,1 and the EHR is often viewed as an electronic documentation system.2 However, the EHR was never intended to be a documentation system. The true nature of the EHR is a database that for now is manually populated by highly educated, very knowledgeable, and uniquely skilled clinicians, which is inarguably unique in the field of data entry. And although preconfigured data-entry aids, such as copy-forward, as well as templates, macros, smart phrases, default text, check boxes, and copypaste are intended to help clinicians efficiently perform data entry in EHRs, the question is, How well do such aids serve health care in capturing essential data? To answer this, we must first understand how health care came to need lipstick on its EHRs in the first place. HOW DID WE GET HERE?
Copy-forward and other EHR data-entry aids are not the issue—but are symptoms of much larger, more significant problems related to the challenges of using EHRs. Dataentry aids constitute workarounds that clinicians use to get their work done; specifically, their data-entry work. Understanding “how we got here” is important to course correcting. But first, it is worth examining all the things we missed along the way. Big Miss #1—The Difference between Business and Health Care
Health care is a business, but it is unique in that it involves clinical work processes, as well as patients, who are unlike any other “consumers.” Particularly on admission to the hospital, they are sick and vulnerable, and they often have to make decisions about which most of them, or their family members, may barely understand. The difference between business and health care begins in the most fundamental properties of work processes. For example, in the retail, banking, and manufacturing businesses 1553-7250/$-see front matter © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjq.2017.04.007
work processes are largely linear, static, redundant, easily understood, easy to implement, and easily measured. In contrast, clinical work processes are chiefly nonlinear, dynamic, multidimensional, and routinely individualized, with a narrow margin of tolerance for disruption. Because of these differences, technology “reacts” differently in health care than in business, and these “reactions” were largely unanticipated. In the United States, the resulting negative consequences were substantial and broadly felt because of the widespread implementation of EHRs, not just across organizations but across an entire industry in a relatively short time, reflecting the impact of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, which focused largely on the accelerated adoption of EHRs.3 For example, in 2014, 76% of nonfederal acute care hospitals had implemented at minimum a basic EHR system with clinician notes, representing a 27% increase from the previous year and a more than eightfold increase since 2008.4 Following rapid and widespread implementation of EHRs, preventable costs, rework, safety issues, and dissatisfaction resulted, and have continued to be reported.5–7 Failure to appreciate the difference between business and health care led us into the next big miss. Big Miss #2—Simple Vs. Complex Software
Many health care information technology (health IT) professionals came out of the business world or the business side of health care. In either case, they focused largely on traditional business processes and associated software, such as financial, human resources, or supply chain management— areas not unique to health care. These areas typically use simple software, meaning “simple” from an end user’s perspective. Simple software applications such as e-mail, word processing, and spreadsheets require a minimum level of knowledge to use, accommodating a wide range of education among the end users. There are few screens and simple work flows, which together make them easy to learn and use for most end users. Complex software applications, on the other hand, have many types of end users and require specific knowledge— “domain” knowledge—to use. These applications have multiple unique screens and features, such as tabs, side menus, drop-down menus, drawers, and slides. Nonlinear, complex work flows require end users to navigate in multiple directions through features such as screens and menus, which are individualized to each patient.
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Linda Harrington, PhD, DNP, RN-BC
The EHR, as one such complex software application, represents a “big miss,” with significant disruption to the health care environment. Also, it has incurred enormous time, cost, and effort to implement—another—indicator of its complexity. Consider that its implementation and ongoing use and maintenance have necessitated the deployment of instructional designers, train-the-trainers, end-user trainers, one-on-one training, and at-the-elbow support “super users,” as well as the provision of “sandboxes” or “playgrounds” for practice using the EHR, weekly updates, tip sheets and pocket guides, clinical help desks, remote support, user groups and list serves, adoption programs, scribes, and clinical documentation improvement programs—as well as the data-entry aids. Because we missed the fact that EHRs are complex software, we have had continuing significant issues with usability, the next big miss. Big Miss #3a—Usability
Usability, which refers to “how useful, usable, and satisfying a system is for the intended users to accomplish goals in the work domain by performing certain sequences of 8 tasks,” (p. 1056) can, if suboptimal, result in inefficiencies, workarounds, errors, safety issues, loss of data, and end user dissatisfaction, among other consequences.9–12 Surveys on EHR satisfaction have consistently reported dissatisfaction. For example, in a survey involving 13,650 licensed RNs in the United States, 92% of the respondents were dissatisfied with inpatient EHRs.13 Disruption in productivity, communication, and work flow, which all reflected problems in usability, were cited as three top dissatisfiers. Usability, then, was a big miss, reflecting the dependence on complex software in the unique business of health care. Work flow is part of usability but is considered as a big miss in its own right because of its significance. Big Miss #3b—Work Flow
Issues with work flow, particularly as it pertains to EHRs, reflect the differences between business and clinical work processes, plus the fact that EHRs are a complex software application. Clinical work flow is multidimensional, entailing cognition, context, communication, collaboration, coordination, and exceptions.14 The strategies that have been undertaken to “fix” EHRs usually address one or more of these dimensions. One example of the failure to understand the multidimensional nature of clinical work flow lies in the use of swimlane diagrams15 and business process maps16 to measure clinical work flows. These tools rest on the assumption that work processes are linear, static, redundant, easily understood, easy to implement, and easily measured— which clinical work flow is not. Examine swimlane diagrams as used in your organization to define clinical work flow. What do you see? They are largely the physical steps of a process. How often do you see the dimensions of cognition, context, communication, collaboration, coordination, and exceptions?14 This was a huge
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miss because the clinical processes used by clinicians in their practice are largely—perhaps more than 50%—cognitive in nature.17 The miss on work flow is exacerbated by the next big miss, cognitive load. Big Miss #4—Cognitive Load
Simply defined, cognitive load refers to mental effort being used in working memory. It refers to all the things that nurses and other clinicians must recall, aggregate, and analyze in concert with their own knowledge when caring for patients. EHRs are intended to reduce cognitive load by facilitating clinical decision support. Yet in their current state, EHRs may do the opposite. Suboptimal EHR usability will be reflected in the associated cognitive load—the worse the usability, the worse the impact on cognitive load.18,19 Poor usability necessitates additional training, thereby increasing memory requirements and thus cognitive load associated with use of the EHR. Furthermore, an EHR’s usability changes in turn as it is updated and upgraded, necessitating unlearning and new learning, further adding to the negative impact on the cognitive load. While some updating and upgrading may be unavoidable, better usability of EHRs would improve ease of learning and use, thereby reducing the impact on cognitive load. The cognitive load imposed by an EHR also reflects the need to navigate through numerous screens, slides, drawers, and menus to find the location to document information— and to then remember the location. Cognitive load further increases by having to remember, when the data are required in formulating opinions and making clinical decisions, where in the EHR that different categories of data can be found. The EHR–associated increases in cognitive load can have negative consequences, such as errors and near misses, as richly documented in the literature.10 Usability, including work flow, misses take us to the next big miss of optimization. Big Miss #5—Optimization
Software development involves defined processes specified in methods such as waterfall20 or agile.21 In both methods, there are appropriate strategies for optimization. The big miss as it pertains to EHRs was the failure to optimize until after implementation. The waterfall method, for example, entails a linear approach of planning, designing, building, testing, and implementing. Yet nonlinear aspects may nonetheless be inherent, as when the testing phase results in the need for redesign and rebuild—requiring retesting. However, this would be done before implementation and would not disrupt the clinical environment. Optimization, particularly in a complex software application such as EHRs, should primarily occur in the planning and design phases, and secondarily, in the testing phase— and not following the implementation phase. This is not only the best approach for improving usability, reducing training requirements, and decreasing cognitive load of clinicians
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but is also by far the least expensive. This is illustrated by Boehm’s cost of change curve in software engineering, created more than 40 years ago.22 Performing optimization that is focused on improving ease of use after implementation necessitates going back and redesigning, rebuilding, retesting, and then retraining all users to implement the new changes. Alongside these change points are unnecessary costs and unnecessary disruptions for clinicians and patients. THE WAY FORWARD
The article, “Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings,” by Patterson et al., in the current issue of The Joint Commission Journal on Quality and Patient Safety,23 provides thoughtful insights and recommendations for using copy-forward in EHRs. The authors—experts in informatics and quality and patient safety—highlight both the benefits of improved documentation efficiency and the associated risks to quality and patient safety. Yet they do not proffer either endorsement or opposition to the use of copyforward. Instead, drawing on the literature, particularly the work of the Partnership for Health IT Patient Safety’s safe practice recommendations for the use of copy/paste for EHRs,24 they offer a balanced viewpoint intended to provide helpful guidance to enable “safe use of copy-forward in flow sheet documentation by nursing personnel in the inpatient clinical setting,”23(p. 3) Yet given the significant problems associated with the use of EHRs, as I have argued, no safe use of copy-forward or other data-entry aids can be assumed. The very existence of data-entry aids may be indicative of the most important miss of all—the value of data—and the significance of that miss in the transformation of health care. As Patterson et al. point out, copy-forward doesn’t improve the value of data but instead can degrade it by producing inaccurate and outdated data. Stop and consider: Why did we implement these mega-million dollar EHRs? Was it so we could have an electronic documentation system, a goal abetted by using data-entry aids? Or was it to use the data to transform health care as other industries have done? The data in today’s EHRs can be viewed as a collection of “data we’ve always collected”—including incomplete data, accurate data, inaccurate data, timely data, outdated data, data that are never used or never will be used, duplicate data, conflicting data, and missing data that are needed but not collected. Copy-forward, as well as other data-entry aids, in combination with EHR design issues, serve to degrade the value of EHR data and the outcomes associated with using the data, such as in patient care, quality improvement, research, risk management, billing, regulatory requirements, population reporting, and more. But is simply removing these data-entry aids enough? The way forward in the transformation of health care to a value-based system is built on data, and the value of those data will affect the results achieved. For example, Patterson
3
et al. suggest examining the use of digital photographs to render digital images in the EHR that document wound assessments23 such as in pressure ulcers. Most people are very familiar with the technology, as digital cameras routinely reside on mobile phones used to capture pictures or videos and downloaded to personal computers or websites for sharing. An alternative to digital photography would be the use of subepidermal moisture (SEM) scanning using a wireless, handheld, wound assessment device that assesses the presence or absence of pressure-induced tissue damage beneath the skin such as occurs in pressure ulcers.25–27 Available for use in Europe and Canada, the device was conceived by Barbara Bates-Jensen, a wound care expert and professor at the University of California, Los Angeles.28 Although both approaches render digital images, the value of the data and what is gained from the data differ significantly. Digital photography renders a two-dimensional (2-D) image that can be analyzed by clinicians or computers to provide estimates of size, shape, colors, and so on, the accuracy of which is dependent, for example, on changes in the distance from the wound to the camera and changes in colors that reflect the use of topical treatments. The SEM Scanner creates a three-dimensional (3-D) image that can only be analyzed by computers, as the “third dimension” exists below the skin. The value of the data differs whereby topical photographs support observational changes in pressure ulcers that have broken the skin, while 3-D tissue scanning affords prevention, early detection, early intervention, and objective analysis of treatment progress with pressure ulcers. Patterns can be recognized in the third dimension that cannot be detected in the second dimension, as reflected in the greater value of the data generated by the SEM scan. This example helps to answer the question asked in the beginning of this editorial about how well EHR data-entry aids serve health care in capturing essential data. It also highlights the needed purpose of the EHR user interface from one that primarily is data receiving on the clinician’s manual entry to one that is information giving to the clinician. The value of the data provided should be determined by the nature of the information given, and the subsequent actions that can be taken and results that can be achieved. The lessons learned from the big misses will continue to be important as usability, work flow, and optimization are considered in the delivery of the actionable and beneficial information that clinicians need. CONCLUSION
Copy-forward is today’s solution to what needs to become yesterday’s problem. With the appropriate evolution of EHRs, in which the data that are captured are those that provide the information clinicians need, the need for copy-forward and other data-entry aids should disappear. Conflicts of Interest. The author reports no conflicts of interest.
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Linda Harrington, PhD, DNP, RN-BC
Linda Harrington, PhD, DNP, RN-BC, is Professor, Baylor College of Medicine, Houston, and Digital Strategy Consultant. Please address correspondence to Linda Harrington, [email protected].
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REFERENCES 1. Tsou AY, et al. Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration. Appl Clin Inform. 2017 Jan 11;8:12– 34. 2. Arrowood D, et al. Integrity of the healthcare record: best practices for EHR documentation. J AHIMA. 2013;84(8):58–62. 3. US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology. Federal Health IT Strategic Plan, 2015–2020. Sep 21, 2015. Accessed April 27, 2017. https://www.healthit.gov/sites/ default/files/9-5-federalhealthitstratplanfinal_0.pdf. 4. US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology. Adoption of Electronic Health Record Systems Among U.S. Non-Federal Acute Care Hospitals: 2008–2014. Charles D, Gabriel M, Searcy T. ONC Data Brief, no 23. Apr 2015. Accessed April 27, 2017. https://www.healthit.gov/sites/ default/files/data-brief/2014HospitalAdoptionDataBrief .pdf/. 5. Middleton B, et al. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. J Am Med Inform Assoc. 2013;20(e1):e2–8. 6. Graber ML, Johnston D, Bailey R. Report of the Evidence on Health IT Safety and Interventions: Final Report. Washington, DC: US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology, 2016. Accessed on April 27, 2016. https://www.healthit.gov/sites/default/files/task_8_1_final _508.pdf. 7. Shanafelt TD, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836–848. 8. Zhang J, Walji M. TURF: toward a unified framework of EHR usability. J Biomed Inform. 2011;44:1056–1067. 9. Staggers N, et al. Nursing-centric technology and usability: a call to action. Comput Inform Nurs. 2015;33:325–332. 10. Zahabi M, et al. Usability and safety in electronic medical records interface design: a review of recent literature and guideline formulation. Hum Factors. 2015;57:805–834. 11. Neri PM, et al. Emergency medicine resident physicians’ perceptions of electronic documentation and workflow: a mixed methods study. Appl Clin Inform. 2015 Jan 21;6:27– 41. 12. Adler-Milstein J, et al. Crossing the health IT chasm: considerations and policy recommendations to overcome current challenges and enable value-based care. J Am Med Inform Assoc. Epub 2017 Mar 15. Accessed Apr 27, 2017.
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https://academic.oup.com/jamia/article-lookup/doi/10 .1093/jamia/ocx017. PRWeb. Hospital Nurses Forced to Develop Creative Workarounds to Deal with EHR System Flaws; Outdated Technologies and Lack of Interoperability, Reveals Black Book. Oct 17, 2014. Accessed Apr 27, 2017. http://www .prweb.com/releases/2014/09/prweb12182208.htm. Harrington L, Harrington C. Usability Evaluation Handbook for Electronic Health Records. Chicago: Healthcare Information and Management Systems Society, 2014. TechTarget. Swimlane Diagram. WhatIs.com. Accessed Apr 27, 2017. http://whatis.techtarget.com/search/query ?q=swimlane+diagram. TechTarget. Business Process Map. WhatIs.com. Accessed Apr 27, 2017. http://whatis.techtarget.com/search/query ?q=business+process+map. National Research Council. Computational Technology for Effective Health Care: Immediate Steps and Strategic Direction. Washington, DC: National Academies Press, 2009. Horsky J, Zhang J, Patel VL. To err is not entirely human: complex technology and user cognition. J Biomed Inform. 2005;38:264–266. Peute LW, et al. Reducing clinicians’ cognitive workload by system redesign; a pre-post think aloud usability study. Stud Health Technol Inform. 2011;169:925–929. TechTarget. Waterfall Model. WhatIs.com. Accessed April 27, 2017. http://searchsoftwarequality.techtarget.com/definition/ waterfall-model. TechTarget. Agile Software Development (ASD). WhatIs.com. Accessed April 27, 2017. http://searchsoftwarequality .techtarget.com/definition/agile-software-development. Boehm B. Software engineering. IEEE Trans Comput. 1976; 25:1226–1241. Patterson ES, et al. Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings. Jt Comm J Qual Patient Saf. 2017;43. ECRI Institute. Copy/Paste: Prevalence, Problems, and Best Practices. Health Technology Assessment Information Service™ Special Report. Oct 2015. Accessed Apr 27, 2017. https://www.ecri.org/Resources/HIT/HTAIS_Copy_Paste _Report.pdf. Clendenin M, et al. Inter-operator and inter-device agreement and reliability of the SEM Scanner. J Tissue Viability. 2015;24:17–23. Bates-Jensen BM, et al. Subepidermal moisture predicts erythema and stage 1 pressure ulcers in nursing home residents: a pilot study. J Am Geriatr Soc. 2007;55:1199– 1205. Bates-Jensen BM, et al. Subepidermal moisture differentiates erythema and stage I pressure ulcers in nursing home residents. Wound Repair Regen. 2008;16:189–197. Wounds International. Scanner Could Hold Key to Cost Savings in Pressure Ulcer Prevention. Jan 20, 2017. Accessed Apr 27, 2017. http://www.woundsinternational.com/news/ view/scanner-could-hold-key-to-cost-savings-in-pressure -ulcer-prevention.
Copy-Forward in Electronic Health Records: Lipstick on a Pig Linda Harrington, PhD, DNP, RN-BC
"P
utting lipstick on a pig” is a porcine proverb about how superficial changes, such as lipstick, are used in an attempt to disguise the true nature of something, as also reflected in the use of copy-forward functionality in the electronic health record (EHR). Copy-forward is a form of electronic documentation that allows EHR users to copy past electronic documentation forward to a current location without retyping it,1 and the EHR is often viewed as an electronic documentation system.2 However, the EHR was never intended to be a documentation system. The true nature of the EHR is a database that for now is manually populated by highly educated, very knowledgeable, and uniquely skilled clinicians, which is inarguably unique in the field of data entry. And although preconfigured data-entry aids, such as copy-forward, as well as templates, macros, smart phrases, default text, check boxes, and copypaste are intended to help clinicians efficiently perform data entry in EHRs, the question is, How well do such aids serve health care in capturing essential data? To answer this, we must first understand how health care came to need lipstick on its EHRs in the first place. HOW DID WE GET HERE?
Copy-forward and other EHR data-entry aids are not the issue—but are symptoms of much larger, more significant problems related to the challenges of using EHRs. Dataentry aids constitute workarounds that clinicians use to get their work done; specifically, their data-entry work. Understanding “how we got here” is important to course correcting. But first, it is worth examining all the things we missed along the way. Big Miss #1—The Difference between Business and Health Care
Health care is a business, but it is unique in that it involves clinical work processes, as well as patients, who are unlike any other “consumers.” Particularly on admission to the hospital, they are sick and vulnerable, and they often have to make decisions about which most of them, or their family members, may barely understand. The difference between business and health care begins in the most fundamental properties of work processes. For example, in the retail, banking, and manufacturing businesses 1553-7250/$-see front matter © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjq.2017.04.007
work processes are largely linear, static, redundant, easily understood, easy to implement, and easily measured. In contrast, clinical work processes are chiefly nonlinear, dynamic, multidimensional, and routinely individualized, with a narrow margin of tolerance for disruption. Because of these differences, technology “reacts” differently in health care than in business, and these “reactions” were largely unanticipated. In the United States, the resulting negative consequences were substantial and broadly felt because of the widespread implementation of EHRs, not just across organizations but across an entire industry in a relatively short time, reflecting the impact of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, which focused largely on the accelerated adoption of EHRs.3 For example, in 2014, 76% of nonfederal acute care hospitals had implemented at minimum a basic EHR system with clinician notes, representing a 27% increase from the previous year and a more than eightfold increase since 2008.4 Following rapid and widespread implementation of EHRs, preventable costs, rework, safety issues, and dissatisfaction resulted, and have continued to be reported.5–7 Failure to appreciate the difference between business and health care led us into the next big miss. Big Miss #2—Simple Vs. Complex Software
Many health care information technology (health IT) professionals came out of the business world or the business side of health care. In either case, they focused largely on traditional business processes and associated software, such as financial, human resources, or supply chain management— areas not unique to health care. These areas typically use simple software, meaning “simple” from an end user’s perspective. Simple software applications such as e-mail, word processing, and spreadsheets require a minimum level of knowledge to use, accommodating a wide range of education among the end users. There are few screens and simple work flows, which together make them easy to learn and use for most end users. Complex software applications, on the other hand, have many types of end users and require specific knowledge— “domain” knowledge—to use. These applications have multiple unique screens and features, such as tabs, side menus, drop-down menus, drawers, and slides. Nonlinear, complex work flows require end users to navigate in multiple directions through features such as screens and menus, which are individualized to each patient.
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Linda Harrington, PhD, DNP, RN-BC
The EHR, as one such complex software application, represents a “big miss,” with significant disruption to the health care environment. Also, it has incurred enormous time, cost, and effort to implement—another—indicator of its complexity. Consider that its implementation and ongoing use and maintenance have necessitated the deployment of instructional designers, train-the-trainers, end-user trainers, one-on-one training, and at-the-elbow support “super users,” as well as the provision of “sandboxes” or “playgrounds” for practice using the EHR, weekly updates, tip sheets and pocket guides, clinical help desks, remote support, user groups and list serves, adoption programs, scribes, and clinical documentation improvement programs—as well as the data-entry aids. Because we missed the fact that EHRs are complex software, we have had continuing significant issues with usability, the next big miss. Big Miss #3a—Usability
Usability, which refers to “how useful, usable, and satisfying a system is for the intended users to accomplish goals in the work domain by performing certain sequences of 8 tasks,” (p. 1056) can, if suboptimal, result in inefficiencies, workarounds, errors, safety issues, loss of data, and end user dissatisfaction, among other consequences.9–12 Surveys on EHR satisfaction have consistently reported dissatisfaction. For example, in a survey involving 13,650 licensed RNs in the United States, 92% of the respondents were dissatisfied with inpatient EHRs.13 Disruption in productivity, communication, and work flow, which all reflected problems in usability, were cited as three top dissatisfiers. Usability, then, was a big miss, reflecting the dependence on complex software in the unique business of health care. Work flow is part of usability but is considered as a big miss in its own right because of its significance. Big Miss #3b—Work Flow
Issues with work flow, particularly as it pertains to EHRs, reflect the differences between business and clinical work processes, plus the fact that EHRs are a complex software application. Clinical work flow is multidimensional, entailing cognition, context, communication, collaboration, coordination, and exceptions.14 The strategies that have been undertaken to “fix” EHRs usually address one or more of these dimensions. One example of the failure to understand the multidimensional nature of clinical work flow lies in the use of swimlane diagrams15 and business process maps16 to measure clinical work flows. These tools rest on the assumption that work processes are linear, static, redundant, easily understood, easy to implement, and easily measured— which clinical work flow is not. Examine swimlane diagrams as used in your organization to define clinical work flow. What do you see? They are largely the physical steps of a process. How often do you see the dimensions of cognition, context, communication, collaboration, coordination, and exceptions?14 This was a huge
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miss because the clinical processes used by clinicians in their practice are largely—perhaps more than 50%—cognitive in nature.17 The miss on work flow is exacerbated by the next big miss, cognitive load. Big Miss #4—Cognitive Load
Simply defined, cognitive load refers to mental effort being used in working memory. It refers to all the things that nurses and other clinicians must recall, aggregate, and analyze in concert with their own knowledge when caring for patients. EHRs are intended to reduce cognitive load by facilitating clinical decision support. Yet in their current state, EHRs may do the opposite. Suboptimal EHR usability will be reflected in the associated cognitive load—the worse the usability, the worse the impact on cognitive load.18,19 Poor usability necessitates additional training, thereby increasing memory requirements and thus cognitive load associated with use of the EHR. Furthermore, an EHR’s usability changes in turn as it is updated and upgraded, necessitating unlearning and new learning, further adding to the negative impact on the cognitive load. While some updating and upgrading may be unavoidable, better usability of EHRs would improve ease of learning and use, thereby reducing the impact on cognitive load. The cognitive load imposed by an EHR also reflects the need to navigate through numerous screens, slides, drawers, and menus to find the location to document information— and to then remember the location. Cognitive load further increases by having to remember, when the data are required in formulating opinions and making clinical decisions, where in the EHR that different categories of data can be found. The EHR–associated increases in cognitive load can have negative consequences, such as errors and near misses, as richly documented in the literature.10 Usability, including work flow, misses take us to the next big miss of optimization. Big Miss #5—Optimization
Software development involves defined processes specified in methods such as waterfall20 or agile.21 In both methods, there are appropriate strategies for optimization. The big miss as it pertains to EHRs was the failure to optimize until after implementation. The waterfall method, for example, entails a linear approach of planning, designing, building, testing, and implementing. Yet nonlinear aspects may nonetheless be inherent, as when the testing phase results in the need for redesign and rebuild—requiring retesting. However, this would be done before implementation and would not disrupt the clinical environment. Optimization, particularly in a complex software application such as EHRs, should primarily occur in the planning and design phases, and secondarily, in the testing phase— and not following the implementation phase. This is not only the best approach for improving usability, reducing training requirements, and decreasing cognitive load of clinicians
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but is also by far the least expensive. This is illustrated by Boehm’s cost of change curve in software engineering, created more than 40 years ago.22 Performing optimization that is focused on improving ease of use after implementation necessitates going back and redesigning, rebuilding, retesting, and then retraining all users to implement the new changes. Alongside these change points are unnecessary costs and unnecessary disruptions for clinicians and patients. THE WAY FORWARD
The article, “Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings,” by Patterson et al., in the current issue of The Joint Commission Journal on Quality and Patient Safety,23 provides thoughtful insights and recommendations for using copy-forward in EHRs. The authors—experts in informatics and quality and patient safety—highlight both the benefits of improved documentation efficiency and the associated risks to quality and patient safety. Yet they do not proffer either endorsement or opposition to the use of copyforward. Instead, drawing on the literature, particularly the work of the Partnership for Health IT Patient Safety’s safe practice recommendations for the use of copy/paste for EHRs,24 they offer a balanced viewpoint intended to provide helpful guidance to enable “safe use of copy-forward in flow sheet documentation by nursing personnel in the inpatient clinical setting,”23(p. 3) Yet given the significant problems associated with the use of EHRs, as I have argued, no safe use of copy-forward or other data-entry aids can be assumed. The very existence of data-entry aids may be indicative of the most important miss of all—the value of data—and the significance of that miss in the transformation of health care. As Patterson et al. point out, copy-forward doesn’t improve the value of data but instead can degrade it by producing inaccurate and outdated data. Stop and consider: Why did we implement these mega-million dollar EHRs? Was it so we could have an electronic documentation system, a goal abetted by using data-entry aids? Or was it to use the data to transform health care as other industries have done? The data in today’s EHRs can be viewed as a collection of “data we’ve always collected”—including incomplete data, accurate data, inaccurate data, timely data, outdated data, data that are never used or never will be used, duplicate data, conflicting data, and missing data that are needed but not collected. Copy-forward, as well as other data-entry aids, in combination with EHR design issues, serve to degrade the value of EHR data and the outcomes associated with using the data, such as in patient care, quality improvement, research, risk management, billing, regulatory requirements, population reporting, and more. But is simply removing these data-entry aids enough? The way forward in the transformation of health care to a value-based system is built on data, and the value of those data will affect the results achieved. For example, Patterson
3
et al. suggest examining the use of digital photographs to render digital images in the EHR that document wound assessments23 such as in pressure ulcers. Most people are very familiar with the technology, as digital cameras routinely reside on mobile phones used to capture pictures or videos and downloaded to personal computers or websites for sharing. An alternative to digital photography would be the use of subepidermal moisture (SEM) scanning using a wireless, handheld, wound assessment device that assesses the presence or absence of pressure-induced tissue damage beneath the skin such as occurs in pressure ulcers.25–27 Available for use in Europe and Canada, the device was conceived by Barbara Bates-Jensen, a wound care expert and professor at the University of California, Los Angeles.28 Although both approaches render digital images, the value of the data and what is gained from the data differ significantly. Digital photography renders a two-dimensional (2-D) image that can be analyzed by clinicians or computers to provide estimates of size, shape, colors, and so on, the accuracy of which is dependent, for example, on changes in the distance from the wound to the camera and changes in colors that reflect the use of topical treatments. The SEM Scanner creates a three-dimensional (3-D) image that can only be analyzed by computers, as the “third dimension” exists below the skin. The value of the data differs whereby topical photographs support observational changes in pressure ulcers that have broken the skin, while 3-D tissue scanning affords prevention, early detection, early intervention, and objective analysis of treatment progress with pressure ulcers. Patterns can be recognized in the third dimension that cannot be detected in the second dimension, as reflected in the greater value of the data generated by the SEM scan. This example helps to answer the question asked in the beginning of this editorial about how well EHR data-entry aids serve health care in capturing essential data. It also highlights the needed purpose of the EHR user interface from one that primarily is data receiving on the clinician’s manual entry to one that is information giving to the clinician. The value of the data provided should be determined by the nature of the information given, and the subsequent actions that can be taken and results that can be achieved. The lessons learned from the big misses will continue to be important as usability, work flow, and optimization are considered in the delivery of the actionable and beneficial information that clinicians need. CONCLUSION
Copy-forward is today’s solution to what needs to become yesterday’s problem. With the appropriate evolution of EHRs, in which the data that are captured are those that provide the information clinicians need, the need for copy-forward and other data-entry aids should disappear. Conflicts of Interest. The author reports no conflicts of interest.
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Linda Harrington, PhD, DNP, RN-BC
Linda Harrington, PhD, DNP, RN-BC, is Professor, Baylor College of Medicine, Houston, and Digital Strategy Consultant. Please address correspondence to Linda Harrington, [email protected].
Copy-Forward in Electronic Health Records
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