Information chaos in primary care: Implications for physician performance and patient safety

Journal of the American Board of Family Medicine

Volumn 24, Issue 6, 2011, Pages 745-751

  Beasley, John W ^a,b   Wetterneck, Tosha B ^a,b   Temte, Jon ^a   Lapin, Jamie A ^b   Smith, Paul ^a   Rivera Rodriguez, A Joy ^c   Karsh, Ben Tzion ^a,b  

^a UNIVERSITY OF WISCONSIN SCHOOL OF MEDICINE AND PUBLIC HEALTH   (United States)

^b University of Wisconsin Madison   (United States)

^c AMRL   (United States)

Author keywords

Complexity science; Information management; Medical errors; Practice management; Primary health care

Indexed keywords

ANNOYANCE; ARTICLE; FRUSTRATION; HUMAN; JOB PERFORMANCE; PATIENT INFORMATION; PATIENT SAFETY; PHYSICIAN ATTITUDE; PRIMARY MEDICAL CARE; WORKLOAD;

CLINICAL COMPETENCE; ELECTRONIC HEALTH RECORDS; HUMAN ENGINEERING; HUMANS; INFORMATION MANAGEMENT; PATIENT SAFETY; PHYSICIANS; PRACTICE MANAGEMENT, MEDICAL; PRIMARY HEALTH CARE; WORKLOAD;

EID: 81855189659     PISSN: 15572625     EISSN: 15587118     Source Type: Journal    
DOI: 10.3122/jabfm.2011.06.100255     Document Type: Article

References (49)

1. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA. Primary Care: America's Health in a New Era. Washington, D.C.: National Academies Press; 1996.
2. Starfield B. Primary care. J Ambul Care Manage 1993;16(4):27-37. (Pubitemid 23272330)
3. Elder NC, Graham D, Brandt E, et al. The testing process in family medicine: problems, solutions and barriers as seen by physicians and their staff: a study of the American Academy of Family Physicians' Research Network. J Patient Saf 2006;2(3):25-32.
4. Kuzel AJ, Woolf SH, Gilchrist VJ, et al. Patient reports of preventable problems and harms in primary health care. Ann Fam Med 2004;2(4):333-40. (Pubitemid 39107890)
5. Phillips RL, Dovey SM, Graham D, Elder NC, Hickner J. Learning from different lenses: reports of medical errors in primary care by clinicians, staff, and patients: a project of the American Academy of Family Physicians National Research Network. J Patient Saf 2006;2(3):140-6.
6. Kuo GM, Phillips RL, Graham D, Hickner JM. Medication errors reported by US family physicians and their office staff. Qual Saf Health Care 2008;17(4):286 -90.
7. Makeham MA, Stromer S, Bridges-Webb C, et al. Patient safety events reported in general practice: a taxonomy. Qual Saf Health Care 2008;17(1):53-7. (Pubitemid 351262953)
8. Dovey SM, Meyers DS, Phillips RL, et al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care 2002;11(3):233-8. (Pubitemid 35265252)
9. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med 2009;7(3):254-60.
10. Fernandopulle R, Patel N. How the electronic health record did not measure up to the demands of our medical home practice. Health Aff (Millwood) 2010;29(4):622-8.
11. Karsh BT, Weinger MB, Abbott PA, Wears RL. Health information technology: fallacies and sober realities. J Am Med Inform Assoc 2010;17(6):617-23.
12. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare and Medicaid programs; electronic health record incentive program. Final rule. Fed Regist 2010;75(144):44313-62.
13. Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med 2010;362(12):1066-9.
14. Beasley JW, Hankey TH, Erickson R, et al. How many problems do family physicians manage at each encounter? A WReN study. Ann Fam Med 2004;2:405-10. (Pubitemid 39421106)
15. Abbo ED, Zhang Q, Zelder M, Huang ES. The increasing number of clinical items addressed during the time of adult primary care visits. J Gen Intern Med 2008;23(12):1058-65.
16. Bodenheimer T. Coordinating care-a perilous journey through the health care system. N Engl J Med 2008;358(10):1064-71.
17. Pham HH, O'Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians' links to other physicians through Medicare patients: the scope of care coordination. Ann Intern Med 2009;150(4):236-42.
18. Smith PC, Rodrig AG, Bublitz C, et al. Missing clinical information during primary care visits. JAMA 2005;293:565-71. (Pubitemid 40171238)
19. Institute of Medicine (ed). Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academies Press; 2001.
20. Thielke S, Hammond K, Helbig S. Copying and pasting of examinations within the electronic health record. Int J Med Inform 2007;76S:S122-8.
21. Beasley JW, Hamilton-Escoto K, Karsh B. Human factors in primary care. In: Carayon P (ed). Handbook of Human Factors and Ergonomics in Patient Safety. Mahwah, NJ: Lawrence Erlbaum Associates; 2006:921-36.
22. Salvendy G (ed). Handbook of Human Factors and Ergonomics. 2nd ed. Hoboken, NJ: John Wiley and Sons; 1997.
23. Sanders MS, McCormick EJ. Human Factors in Engineering and Design. 7th ed. New York: McGraw-Hill Science; 1993.
24. Wickens CD, Lee JD, Liu Y, Gordon-Becker S. An Introduction to Human Factors Engineering. 2nd ed. Upper Saddle River, NJ: Pearson Education; 2004.
25. Endsley MR. Towards a theory of situation awareness in dynamic systems. Hum Factors 1995;37:32-64.
26. Hazlehurst B, McMullen CK, Gorman PN. Distributed cognition in the heart room: how situation awareness arises from coordinated communications during cardiac surgery. J Biomed Inform 2007;40(5):539-51. (Pubitemid 47337074)
27. Hogan MP, Pace DE, Hapgood J, Boone DC. Use of human patient simulation and the Situation Awareness Global Assessment Technique in practical trauma skills assessment. J Trauma 2006;61(5):1047-52. (Pubitemid 44737005)
28. Salmon PM, Stanton NA, Walker GH, Jenkins D, Baber C, McMaster R. Representing situation awareness in collaborative systems: a case study in the energy distribution domain. Ergonomics 2008;51(3):367-84. (Pubitemid 351997504)
29. Smith K, Hancock PA. Situation awareness is adaptive, externally directed consciousness. Hum Factors 1995;37(1):137-48.
30. Stanton NA, Stewart R, Harris D, et al. Distributed situation awareness in dynamic systems: theoretical development and application of an ergonomics methodology. Ergonomics 2006;49(12-13):1288-311. (Pubitemid 44489541)
31. Hancock PA, Hoffman JE. Stress and cognitive workload. In: National Research Council (ed). Tactical display for soldiers: human factors considerations. Washington, D.C.: National Academies Press; 1997:129-62.
32. Hancock PA, Szalma JL. Operator stress and display design. Ergon Des 2003;11(2):13-8.
33. Hancock PA, Warm JS. A dynamic model of stress and sustained attention. Hum Factors Oct 1989;31(5):519-37. (Pubitemid 20115243)
34. Endsley MR, Garland DJ (eds). Situation Awareness Analysis and Measurement. Hillsdale, NJ: Lawrence Erlbaum Associates; 2000.
35. Stanton NA, Chambers PRG, Piggott J. Situational awareness and safety. Saf Sci 2001;39(3):189-204. (Pubitemid 32846682)
36. Hancock PA, Desmond PA (eds). Stress, workload and fatigue. Boca Raton, FL, CRC Press; 2000.
37. Endsley MR, Jones DG. Disruptions, Interruptions, and information attack: impact on situation awareness and decision making. Paper presented at: 45th Annual Meeting, Human Factors and Ergonomics Society Annual Meeting, October 8-12, 2001, Minneapolis, MN.
38. Kahneman D, Tversky A, Slovic P. Judgement under Uncertainty: Heuristics and Biases. Cambridge, UK: Cambridge University Press; 1982.
39. Temte J, Grasmick M, O'Halloran P, et al. Mental workload in primary care. Paper presented at: AAFP National Research Network 8th Annual Convocation of Practices and Networks, March 7-9, 2008, Colorado Springs, CO.
40. Brixey JJ, Robinson DJ, Johnson CW, Johnson TR, Turley JP, Zhang J. A concept analysis of the phenomenon interruption. ANS Adv Nurs Sci 2007;30(1):E26-42.
41. Chisholm CD, Dornfeld AM, Nelson DR, Cordell WH. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med 2001;38(2):146-51. (Pubitemid 32702280)
42. Paxton F, Heaney D, Howie J, Porter BA. A study of interruption rates for practice nurses and GPs. Nurs Stand 1996;10(43):33-6.
43. Potter P, Wolf L, Boxerman S, et al. Understanding the cognitive work of nursing in the acute care environment. J Nurs Adm 2005;35(7-8):327-35. (Pubitemid 41134342)
44. Altmann EM, Trafton JG. Task Interruption: Resumption Lag and the Role of Cues. Proceedings of the 26th Annual Conference of the Cognitive Science Society; 2004:42-7.
45. Zheng K, Haftel HM, Hirschl RB, O'Reilly M, Hanauer DA. Quantifying the impact of health IT implementations on clinical workflow: a new methodological perspective. J Am Med Inform Assoc 2010;17(4):454-61.
46. Hancock PA, Weaver JL. On time distortion under stress. Theoretical Issues in Ergonomic Science 2006;6(2):193-211.
47. Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med 2007;5(5):457-61. (Pubitemid 47535978)
48. Stewart EE, Johnson BC. Improve your office efficiency in mere minutes. Fam Pract Manag 2007;14:27-9.
49. Sinsky CA. Improving office practice: working smarter, not harder. Fam Pract Manag 2006;13(10):28-34. (Pubitemid 44905934)