Veterans Administration (VA) Integrated Medication Manager

A traditional medical record does not sufficiently facilitate nor capture the thought process of clinicians, including the conceptualization of conditions and the reasoning used for the choice of treatment. In addition, it does not express the relationships between conditions, treatments and goals effectively, with those relationships generally implied and thus difficult to access. This means that for each new encounter clinicians must re-familiarize themselves with a patient’s record in order to develop and reestablish a mental model of the current status of the patient and a plan of treatment. In addition, providers must review multiple progress notes in order to understand the relationship between established therapy and goals, a time consuming task. As such, conditions are treated in isolation, rather than in the context of a patient’s other conditions or in the context of overall goals.

This project developed a new application called the Integrated Medication Manager (IMM). IMM presents to clinicians an integrated representation of a patient’s status and care process over time. By relating conditions, therapies, and goals in the area of pharmacotherapy, the application allows providers to place orders and plan care directly in the context of these relationships. Data presented in this manner reduces clinicians’ cognitive effort and time needed to absorb data across time, understand relationships among concepts, and undergo decisionmaking strategies. This project specifically focused on the management of hypertension in the setting of the Veterans Healthcare Administration.

The specific aims of this project were to:

• Identify cognitive components of providers’ therapeutic decisionmaking in the field.
• Refine and evaluate the IMM using simulation studies.

For the first aim, qualitative methods including observation, task analysis, and semi-structural interviews were employed. The findings of the observations were shared with the development team to guide them in refining the IMM software. For the second aim, simulation studies with clinicians completing patient assessments were conducted comparing a traditional electronic health record (EHR) to IMM. These studies were used to gain insight into how providers integrate clinical information, including during times of interruptions. The study results indicated that despite minimal training on IMM the time to complete assessments was significantly less than with the traditional EHR. The greatest improvements in time were noted in those simulations in which clinicians writing assessments and plans on complex patients were interrupted. The team hypothesized that IMM presents relationships explicitly and thus the provider does not need to recreate a mental model of the patient after being interrupted.