DISCUSSION

With the new display system all reports are represented on a single screen with critical reports highlighted in red in the outer concentric array and non-critical results in the inner array.  The new display system is a ‘‘button” array that with a cursor ‘‘hover and click” enables the direct display and progressive acknowledgement of represented reports from this simple, invariant format. The structure facilitates the triage of data review: critical results are signed off immediately by the provider and  non-critical  results can be signed off later by the provider or signed out to another member of that health-care team.

R.A.P.I.D. demonstrated superiority compared with the enhanced versions of two standard EHR systems, both in reducing review times and improving accuracy. Clinical report review with the new display is considerably faster than the test results demonstrate, because the reports for EM and EO were grouped in a single stack or file rather than separated from each other by multiple screens as is the usual case with Meditech and Orchard. This change allowed all reports in both Meditech and Orchard to be reviewed sequentially. Without this modification, and depending on the number of screens that would need to be searched to review all reports first on a patient-by-patient basis, then on a data category-by-category basis and finally on a report-by-report basis, the provider would need significant additional time to acknowledge a report in the standard Meditech and Orchard systems. By contrast, for the purposes of the survey the new display system, which normally has a single acknowledgement button, was fitted with a two-button critical/non-critical acknowledgement modification (and thus less efficient) to match the structure of EM and EO. Despite these modifications, the survey results show that R.A.P.I.D. is superior to EM and EO in report acknowledgement time and accuracy. The novel display system, with its simple, invariant button structure, also enables  critical/non-critical reports of any number to be represented on a single screen for acknowledgement.

Non-physician providers frequently overrode both system- designated non-critical and critical reports. These reassignments are carried out in a highly non-random (i.e., decision-based) fashion and suggest that users now apply their own critical settings in their current practice of data review. The capability with R.A.P.I.D. for the user to adjust critical categories/values (Fig. 6) in addition to those defined by the EHR system as well as to set time windows of data reviewed will enable providers to improve patient care.

 

Additional features of the new display system for the user that were not part of the present study include the ability: (a) to toggle directly between displays of individual patient reports and those of larger groups of patients (Fig. 2), (b) to flag changes of critical magnitude (e.g., a hemoglobin drop of 20–30%) (Fig. 6), and (c) to conduct text-based document searches. These capabilities of the new display system, including reviews of text format reports, are demonstrated in the accompanying video [27].

In summary, the new display system is a stand-alone data structure and display format that can integrate data from multiple EHR systems onto a single screen representation. The new display system can be adapted for a hand-held device because the ‘‘stacking” feature generates a simple data display regardless of data complexity. It enhances patient safety through its simple contextual representation of all critical/non-critical data on a  single screen that improves care provider communication.

Data displayed in this new display format would be ideal for use by administrators, compliance officers, researchers, the patients themselves, and in fact anyone with sanctioned access to patient data. On the basis of these results and to quantify the benefit of R.A.P.I.D., we now recommend that a real-time  study  with  the use of complete patient data be conducted. Such a study would allow the full scope of the new display design benefit to be quantified. Further, this study would also enable the test of language-based critical/non-critical report assignment, such as those in the areas of radiology and pathology, as well as the display of critical/non-critical vital sign and drug interaction data.

Beyond its use by practitioners in optimizing patient care, the cur- rent display design will be useful within health care wherever critical data exists randomly within a huge volume of non-critical data. Examples include the use by nurses, in similar fashion  to that we describe  for practitioners, in monitoring the vital signs of all patients. Practice administrators can use the display  design  to monitor  the compliance of a group of many practitioners with care guidelines. The billing office could monitor the payment histories of patients and their insurers.

                                   Fig. 4

A Sign-Off Time Per Report

B Average Sign-Off Time Per Report

                                   Fig. 5

A Non-Critical to Critical Reassignment

E Summary: Critical / Non-Critical Reassignments

B Critical to Non-Critical Reassignment

C Non-Critical to Critical Reassignment

D Critical to Non-Critical Reassignment

                                   Fig. 6

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