Opportunistic Decision Making Information Needs and Workflow in Emergency Care (Texas)

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In high-risk healthcare settings such as the Emergency Department (ED), managing information needs and supporting clinical decision making is critical for patient safety and healthcare quality. Rather than focusing on a single task at a time, ED clinicians are forced to switch between multiple tasks and multiple patients. Many of these task transition decisions are based on unplanned, unorganized, and unpredictable environmental factors. Rather than acting on a global understanding of the department, clinicians make opportunistic decisions, or those that are informed by the local level, such as selecting the next patient based on proximity. This high level of complexity in the ED is a major contributing factor to potentially preventable adverse events.

This project studied information management and decision making among ED clinicians and focused on task transition decisions. The goal was to develop a Work Domain Ontology (WDO) to capture the essence of work in the ED, including the clinical goals, information needs, and the clinical operations of an ED that are required for patient care. The WDO was used to inform evaluation of dashboard displays.

The specific aims of this project were as follows:

  • Develop and validate the WDO of the ED. 
  • Identify the information needs and understand the mechanisms and impacts of opportunistic decision making. 
  • Develop visualizations for increasing situational awareness and supporting decision making. 
  • Evaluate the impact of the visualizations as cognitive interventions. 

Interviews, surveys, and ethnographic observations were used to capture participant workflows and information needs for completing tasks within the ED at three hospitals. Five displays providing a range of information and visual supports were developed using the WDO. The dashboards included: (1) the number of current patients, severity score for each patient, current location of patients, and available beds; (2) status of laboratory and imaging orders; (3) contributing factors to the unit’s current overcrowding score; (4) throughput measures including the duration of each patient’s current stage of care; and (5) workload information for each clinician.

The displays were implemented at 11 hospitals with the aim of providing actionable information for real-time decision making. Formative assessments indicated the dashboards were readily accepted; however, some degree of fine-tuning was needed, such as extending the patient history tracking window from 12 hours to 15 hours and refining timeline graphics. Eye-tracking results indicated users quickly made use of dashboard features and tools. Evaluation of long-term use of the dashboard on quality measures is a potential next step for this project.

Opportunistic Decision Making Information Needs and Workflow in Emergency Care - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS11-198: Understanding Clinical Information Needs and Health Care Decision Making Processes in the Context of Health Information Technology (IT) (R01)
  • Grant Number: 
    R01 HS 021236
  • Project Period: 
    September 2012 - July 2016
  • AHRQ Funding Amount: 
  • PDF Version: 
    (PDF, 213.79 KB)

Summary: Emergency departments (ED) in hospitals are complex, time sensitive, and information intensive environments. ED clinicians monitor constantly changing needs, respond to unpredictable circumstances, and communicate with people as issues arise. ED activities are governed by local rules in which the structure of the system is determined by interaction rather than top-down structure. In this high-risk setting, managing information needs and supporting clinical decisionmaking is critical for patient safety and health care quality. Opportunistic decisionmaking—the unplanned switching in the middle of a task or across multiple tasks—can lead to suboptimal performance. The over-arching objective of this project is to study information management and decisionmaking in the ED and develop interventions to reduce cognitive burden, improve communication, and reduce error. A Work Domain Ontology (WDO), or formal definition and description of the basic abstract structure of work conducted by a system and its users, will be developed for the emergency department. The project will explore ED workflows and decisionmaking processes via focus groups, interviews, and observation of human movement patterns generated by radio identification tags. The study team will develop visualizations as a cognitive intervention and evaluate its impact on human performance and clinical outcomes.

Specific Aims:

  • Develop and validate the Work Domain Ontology (WDO) of the emergency department. (Ongoing)
  • Identify the information needs and understand the mechanisms and impacts of opportunistic decisionmaking. (Ongoing)
  • Develop visualizations for increasing situation awareness and supporting decisionmaking. (Upcoming)
  • Evaluate the impact of the visualization as cognitive interventions. (Upcoming)

2012 Activities:

The investigators received approval from the institution review boards (IRBs) at two of the three study sites. For the third site, which is community-based instead of an academic site, the IRB approval and relationship building is in process.

Data for eight attending physicians for a total of 16 sessions has been collected at the first site to study changes since the initial pilot study (including implementation of an electronic health record system for documentation and computerized physician order entry.) The study team has also conducted surveys and focus groups to validate findings on information needs and communication practices. These efforts will continue over the coming quarters.

Dr. Zhang and his team are working to update the WDO created from previous data collection by incorporating changes that have occurred in the ED workflow. The WDO will now include the roles of trainees and nurses. As last self-reported in the AHRQ Research Reporting System, project progress and activities are completely on track and project budget funds are slightly underspent due to minor delays in the grant contract process and hiring of study personnel.

Preliminary Impact and Findings: Initial findings suggest some changes in the ED workflow with the implementation of an electronic health record system. Among these changes was a decrease in opportunistic decisionmaking. This decrease, although not statistically significant, is likely triggered by the anchoring of physicians to work stations resulting in a reduction of overall movement.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Opportunistic Decision Making Information Needs and Workflow in Emergency Care - Final Report

Franklin A. Opportunistic Decision Making Information Needs and Workflow in Emergency Care - Final Report. (Prepared by University of Texas Health Science Center under Grant No. R01 HS021236). Rockville, MD: Agency for Healthcare Research and Quality, 2017. (PDF, 1.19 MB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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