Brandon's List: A quarterly review of scholarly research useful for the OpenMRS community

I went through the last three months’ publications of the journals listed here and picked out the articles that I think many people in the OpenMRS community would find useful and interesting, along with snippets from the text of the article (not the abstract). These have been selected for implementation managers, product managers, designers, and developers pretending to be any/all of the aforementioned. If people do in fact like this and find it useful, I might continue to produce it quarterly.

I’ve for the most part omitted the vast literature on clinical decision support (CDS). If a CDS squad gets going in OpenMRS, they should really do their own literature review.

:star:” designates my top picks, articles that I think are especially insightful, useful, and brilliantly done.

:lock:” designates articles that are paywalled. If you don’t have access, try asking someone who might.

Physician perceptions of documentation methods in electronic health records

“The burden of documentation for billing purposes is heavy. Often lost in the effort to click all the right boxes for billing is the actual narrative of the patient’s story, what the [doctors] impression of what is actually going on with the patient is.”

A subset of comments featured survey responders trying to imagine or design what an improved EHR system would look like (Table 4). The majority of these ideas centered around more physician involvement in designing the templates, with increased customizability for individual providers. Another very common suggestion was improved voice recognition that integrates directly into the charting system. Finally, many respondents expressed a desire that different EHR systems could interface with and share data with each other, allowing more cohesion to a patient story between healthcare systems.

Evaluation of an optimized context-aware clinical decision support system for drug-drug interaction screening

Electronic health records (EHRs) linked with computerized physician order entry (CPOE) and medication-related clinical decision support systems (CDSS) can decrease prescription errors and consecutive adverse drug events, but evidence of the effect on mortality and morbidity remains mixed [[4], [5], [6], [7], [8], [9]]. Current CDSS for drug-drug interaction (DDI) screening are often overly sensitive generating a high alert burden and alerts with low specificity leading to alert fatigue and high override rates [[10], [11], [12]]. Clinicians override both clinically significant and insignificant alerts, which compromises the primary objective of patient safety. Consequently, measuring alert burden and acceptance rates are important indicators of process outcomes of CDSS [13,14]. Several optimization strategies proved to make CDSS for DDI screening more effective. Categorizing DDIs by severity and adjusting the way in which the alerts are presented (interruptive or non-interruptive) accordingly increased compliance rates [15]. The specificity of the alerts can be improved by making the alerts more patient-specific, for example by taking into account patients’ characteristics and laboratory test results [11,16]. Providing recommendations in the alert screen and requiring override reasons also improved CDSS effectiveness [17,18]. However, most of these interventions only slightly to moderately improved process or patient outcomes [5,6,16].

:star: Putting the social back into sociotechnical: Case studies of co-design in digital health

Our empirical findings illustrate that, although necessary, technical, mechanistic co-design is not sufficient for mainstreaming technology in health care. Instead, emphasis on the ongoing, social co-production of technology-supported services may allow better engagement with the tensions that surface in complex technology projects. A preliminary co-design “phase” helps the technology get to a reasonably mature stage, but iterative, adaptive co-design of the technology in “perpetual beta” mode may enable it to become sustainably embedded in the wider service.

Reorienting our focus toward technology-supported services also implies a shift from co-designing with technology users to co-designing with patients as service users, and with healthcare staff as professionals. Health technologies create new forms of knowledge and new possibilities for care that place (sometimes hidden) burdens on patients and carers, and require fundamental changes to staff roles and service models.43 Negotiating underpinning values and standards built into new models of technology-supported care, as well as engaging staff and patients in co-shaping pathways, routines and shared visions, becomes important.43 As Swinglehurst44 suggested, health technologies become enmeshed in the display and circulation of authority in clinical consultations, legitimizing particular ideals of what good care consists of. Distancing key groups from co-design may lead to disengagement from the articulations of the technology and divergence from work practices that could affect the success of technology projects. Instead, resilient organizations would support and encourage staff to continually bridge the gap between work-as-imagined and work-as-done, as well as feeding back into system learning and the evolution and adaptation of work routines and practices, to make health care safer.45

Factors affecting the mature use of electronic medical records by primary care physicians: a systematic review

In 4 studies [7, 41, 43, 45], EMR system factors impacted the extent to which physicians used advanced EMR features. In [45], the automaticity of advanced EMR features was found to impede the use of advanced features. This study found that physicians perceived that automaticity in advanced EMR features resulted in errors, where participants (> 60%) reported errors such as typos, adding information to the wrong patient chart, and unintentionally selecting an erroneous item (diagnosis or medication) from a scroll-down list [45]. Additionally, participants perceived that the use of predefined templates negatively impacted patient safety, and they preferred typing over using this advanced feature [45]. Furthermore, a study [7] found that the complexity of EMR features led to physicians having trouble understanding how to use EMR functions and how to incorporate these functions into their work routines. In other studies [41, 43, 45], the EMR system’s user-friendliness and ease of use were important for fuller usage of the system by family physicians. A study [43] found that EMR systems that had comprehensive clinical functionalities (e.g., providing prescriptions electronically) were used more extensively because physicians saw such features as more useful because these clinical functionalities better supported the main clinical tasks they undertook in primary care settings.

The effects of clinical decision support system for prescribing medication on patient outcomes and physician practice performance: a systematic review and meta-analysis

The most critical CDSS system factors for outcome improvement are: alignment of guidelines with registered and EHR data to make decisions about each individual patient [29, 31, 33]; the short massages that include only necessary alerts such as drug interaction alerts sent in the right time for prescribing and user-friendly interface for saving physicians’ time [18, 20, 44, 45, 47, 48]; giving the choice to users by enabling them to close the alert window and move through next steps or provide uninterrupted alerts [37,38,39,40,41, 56]; the behaviors of physicians and patients which have positive effects on outcomes in CDSS-equipped environments through collaboration, following guidance, recommendations, alerts, and reminders that the system provides [37, 42]. Also, considering physician perception in defining the importance of alerts helps better understand the interruption status of alerts [37,38,39,40,41].

OpenMRS as a global good: Impact, opportunities, challenges, and lessons learned from fifteen years of implementation :lock:

Recommendations to overcome key risks and implementation challenges.

• Usability is an important aspect of a successful implementation. Historically OpenMRS has been used as a platform on which individual implementers can build their own forms and user interface (UI) elements, leaving usability issues to implementers. There exists a need for community resources to promote EHR usability such as creating a shelf-ready version of OpenMRS with a standard UI and the integration of human centered design into the development process.

• Strong education programs for OpenMRS are needed with resource availability to train organizations and individuals in developing, implementing, maintaining, and contributing to OpenMRS.

• Skilled consultants & software contractors that provide the technical support required for adopting, configuring, rolling out, and maintaining OpenMRS (OpenMRS Service Providers) can reduce a commonly cited barrier to implementation - the need for technical talent & resources.

• Additional support, incentives, and advocacy are needed to harmonize the OpenMRS community, including implementers and donors, to ensure that implementations are using the most recent stable version of OpenMRS.

• Groups of implementers working on similar use cases need a platform to collaborate on functionality. This would help ensure that use case-specific features are bundled in distribution modules (such as operational workflows, user interfaces) and common features that are context-independent (such as metadata management, offline functionality, security) are a part of OpenMRS core.

:star: Analysis of the cognitive demands of electronic health record use :lock:

This study aimed to understand the cognitive requirements of clini- cians’ EHR use in different clinical environments and roles. The ACTA interviews resulted in detailed evidence of the cognitive demands associated with EHR usage. The rich data collected from the cognitive task analyses led to a comprehensive set of 22 thematically organized cognitive demands drawn across roles, disciplines, and technologies, with an explicit focus on user interactions with EHRs motivated by the JCS perspective. The set of cognitive demands organized thematically above validate and extend prior work that identifies the type of cogni- tive work involved in diverse clinical settings, such as inpatient resident teams [30]outpatient pediatrician offices [27], and general care [22]. These 22 cognitive demands also provide comprehensive guidance for EHR design and evaluation that corroborates and extends findings from prior case studies of individual EHR sub-systems and specific clinical disciplines and roles. Using the ACTA methodology allows for eliciting and documenting those cognitive demands with detailed evidence that substantiates them in actionable terms, namely for the design and evaluation of effective EHR systems.

The insights of this article are so numerous as to be difficult to summarize. You really just have to read it.

Optimizing the electronic health record: An inpatient sprint addresses provider burnout and improves electronic health record satisfaction :lock:

Improvement in provider opinion about the EHR was achieved through the 3-pronged intervention of dedicated provider training on use of the EHR, facilitating individual clinician EHR personaliza- tion, and delivery of EHR content optimizations. These 3 interven- tions worked synergistically because personalization could be done immediately with training on the newly configured tools delivered. It was critical that we involve the frontline clinicians in the design of each intervention to ensure each piece fit into their workflows.

If you got some value out of this, hit the heart button to let me know. If enough people find it useful I’ll do this quarterly (next time in June). And hit the notifications button → “Watching” to get notified when it comes out.


I am liking and watching this thread for sure :eyes: Thanks so much @bistenes :100:

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This is an excellent service and would recommend that others append good papers that they find as well! Thank you!