Critical Diagnoses

By Anna Lynn Spitzer

Irvine, Ca, June 28th, 2013 -- As doctors and nurses rush through the busy emergency department in a large Southern California hospital, they probably don’t notice the petite young woman with the dark hair and wire-framed glasses standing to the side, scrawling in her notebook. And that’s fine with Yunan Chen. 

The UC Irvine informatics assistant professor analyzes technology’s impact on the medical field; she gathers data by studying healthcare providers as they navigate their daily routines.

How often do they stop to enter information in the Electronic Medical Record (EMR) System? Can they find what they’re looking for in the patient record? Does the system make them more efficient or slow them down? Is it compatible with their workflow or are they creating “workarounds” that better serve their own needs?

Chen: "Unless we do these studies we really don't know what critical issues are."

A break in the action often finds her interviewing the providers and in many cases, their patients. Sometimes she relies on videotaped exam-room conversations; other times she observes doctor-patient interactions. (She excuses herself during physical examinations: “I’m interested in the technology use, not the private stuff.”)

The medical informatics researcher wants to understand not only what the electronic systems can do but how they are used. She seeks to make EMR systems and the wealth of data they contain more responsive to doctors and nurses, as well as researchers, staff, administrators, policymakers and government officials who can benefit from the information treasure trove as well. 

“The information infrastructure will fundamentally change the way medical work is practiced,” she says. “It’s important to know how we can design it better – to make it more intelligent and to serve multiple people.”

She finds some doctors frustrated by the technology, while others worry about falling behind schedule. “It’s urgent to find methods that are more effective,” she says. “If people are satisfied with the system they will use it.”

Dr. John Mattison has extensive experience with EMRs. The chief medical information officer in Kaiser’s Southern California region has worked in multiple fields, including primary care, preventive medicine, emergency services and critical care. “Yunan’s work is remarkably important … especially right now,” he says.

“The problem is that the health record system itself doesn’t really buy you much; in fact, it really slows doctors down and it has increased costs. There’s been a huge backlash and it’s growing into an avalanche of complaints.”

Problems are numerous. Electronic medical records must be loaded with customized content based on doctors’ specialties. Information can’t be shared across platforms. And workflow must constantly undergo adjustments to maximize efficiency.  
“People who designed the software thought it would work one way but it just didn’t work. So we have to find a way around it just to get our job done,” Mattison says.

Take informal communication, for example. Despite the expensive electronic systems at their fingertips, Chen has observed doctors and nurses scribbling notes to themselves. 

Doctors managing large caseloads don’t have time to scroll through pages and pages of electronic patient data to locate key information. She watches them jot down pertinent facts from the EMR and carry a clump of hand-written notes with them as they meet with patients. 
In addition, the EMR lends itself more easily to discrete data – diagnoses, lab orders, prescriptions and the like. But doctors and nurses still carry hand-written missives to remind themselves of tasks they need to accomplish. “These notes are not formalized enough to become part of the EMR system but they are important for the workflow. The formal system does not support this.” 

She hopes her research ultimately will lead to better medical practices and patient care. “When formal systems cannot support certain parts of people’s work practice, what does that mean? And how can we better design technology to support that kind of practice?”

Chen’s studies have also taken her to outpatient clinics, where she analyzes doctors’ and patients’ interactions around technology. “If you’re a chronic care patient and you only have 20 minutes with your doctor, you want the doctor to be efficient so he has time to talk to you. You want him to be able to access the right information, ask the right questions.”

Not surprisingly, patients also want to know that they – not the computer – are commanding the doctor’s attention. Perhaps the answer is a new hardware configuration. Or maybe it’s a mobile device. “Unless we do these studies,” she says, “we really don’t know what the critical issues are.” 

One of her projects tracked the number of times per task the doctor moved the computer mouse. Some tasks, Chen learned, could require several hundred mouse clicks: that type of information that can help inform future systems. Perhaps certain features can be grouped together or placed in specific patterns on the screen. “If doctors have to move the mouse back and forth 50 times during one patient visit, why can’t we make something easier for them to use?” she wonders.

Mattison believes these changes can “absolutely, unequivocally” increase doctors’ efficiency while reducing costs. “At Kaiser, that’s already happening but we’re the exception,” he says. “Smaller institutions don’t have the budget to [make these changes] themselves. They’re struggling to get it right and Yunan’s work is going to help them.”

While she doubts that health practices will ever be completely paper-free, Chen does envision a technology-rich future with systems responsive to their users. “I’m hoping in 15 to 20 years there will be a sociotechnical environment that best supports the flow of information and collaboration, makes sense and allows providers to use information effectively,” she says. “Whenever you need information you can access it in the format you prefer and use it in an efficient and effective manner.”