Physician activity during outpatient visits and subjective workload.
We describe methods for capturing and analyzing EHR use and clinical workflow of physicians during outpatient encounters and relating activity to physicians' self-reported workload. We collected temporally-resolved activity data including audio, video, EHR activity, and eye-gaze along with post-visit assessments of workload. These data are then analyzed through a combination of manual content analysis and computational techniques to temporally align streams, providing a range of process measures of EHR usage, clinical workflow, and physician-patient communication. Data was collected from primary care and specialty clinics at the Veterans Administration San Diego Healthcare System and UCSD Health, who use Electronic Health Record (EHR) platforms, CPRS and Epic, respectively. Grouping visit activity by physician, site, specialty, and patient status enables rank-ordering activity factors by their correlation to physicians' subjective work-load as captured by NASA Task Load Index survey. We developed a coding scheme that enabled us to compare timing studies between CPRS and Epic and extract patient and visit complexity profiles. We identified similar patterns of EHR use and navigation at the 2 sites despite differences in functions, user interfaces and consequent coded representations. Both sites displayed similar proportions of EHR function use and navigation, and distribution of visit length, proportion of time physicians attended to EHRs (gaze), and subjective work-load as measured by the task load survey. We found that visit activity was highly variable across individual physicians, and the observed activity metrics ranged widely as correlates to subjective workload. We discuss implications of our study for methodology, clinical workflow and EHR redesign.
Veterans Medical Research Foundation, 3350 La Jolla Village Dr, San Diego, CA 92161, United States. Electronic address: acalvitti@ucsd.edu.
Alan
A
Calvitti
Department of Biomedical Informatics and Intelligent Systems Program, University of Pittsburgh, 5607 Baum Blvd, Pittsburgh, PA 15206, United States.
Harry
H
Hochheiser
Veterans Medical Research Foundation, 3350 La Jolla Village Dr, San Diego, CA 92161, United States.
Shazia
S
Ashfaq
VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161, United States.
Kristin
K
Bell
Department of Medical Informatics UC Irvine, Irvine, CA 92697, United States.
Yunan
Y
Chen
Department of Hospital Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States.
Robert
R
El Kareh
VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161, United States.
Mark T
MT
Gabuzda
Department of Family Medicine and Public Health, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States.
Lin
L
Liu
Veterans Medical Research Foundation, 3350 La Jolla Village Dr, San Diego, CA 92161, United States.
Sara
S
Mortensen
VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161, United States.
Braj
B
Pandey
Department of Computer Science and Engineering, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States.
Steven
S
Rick
Department of Communication, Texas A&M University, 400 Bizzell St, College Station, TX 77840, United States.
Richard L
RL
Street
Department of Computer Science and Engineering, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States.
Nadir
N
Weibel
Department of Biomedical Informatics, University of Utah, SLC, VA, Salt Lake City, UT, United States.
Charlene
C
Weir
Veterans Medical Research Foundation, 3350 La Jolla Village Dr, San Diego, CA 92161, United States; Department of Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States; West Health Institute, 10350 N. Torrey Pines Road, La Jolla, CA 92037, United States.
Zia
Z
Agha
D003625:Data Collection; D057286:Electronic Health Records; D006801:Humans; D010045:Outpatients; D010817:Physician-Patient Relations; D010820:Physicians; D010818:Practice Patterns, Physicians'; D014741:Video Recording; D016526:Workload
Clinical workflow; Computational ethnography; Electronic health record; Time-motion; Workload