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The study by the American Medical Association (AMA) and MedStar Health National Center for Human Factors in Healthcare was conducted at four U.S. health systems, two that use the Epic electronic health record (EHR) and two that use the Cerner EHR. Clinical experts developed six common clinical scenarios, which were loaded into the EHRs at each site.
Twelve to 15 emergency physicians per site, who regularly use the EHR, participated in the study. Participants worked in a quiet testing room at each site. Researchers recorded eye-tracking data and screen capture video to understand where participants were looking on the EHR interface, and the number of clicks and keystrokes required to perform each scenario. Fictitious patient data was used in all videos.
Scenario 1 – Pediatric Injury: A 7-year-old female comes into the emergency department (ED) by ambulance and is complaining of severe arm pain. EMS put her arm in a sling and upon physical exam, she has a notable deformity of the left wrist and she notes a numbness in her thumb and first finger. Please use the EHR to place an IV and order Morphine 0.1mg/kg IV STAT. Also, order a plain film X-ray of the patient’s left forearm, elbow, and wrist. Lastly, place the patient on NPO status. The X-ray comes back and the present impression reading from radiology shows a posteriorly displaced comminuted fracture of the distal radius/ulna. Because your facility does not generally treat pediatric, orthopedic injuries of this severity, you are now going to transfer the patient to a specialty hospital. Please transfer the patient to [INSERT LOCATION].
Scenario 2 – Back Pain: A 37-year-old patient presents to the ED with severe midline lower back pain. The patient denies previous back pain or trauma. The patient also denies a history of smoking, alcohol, and illicit drug use. On exam, you find the patient has bilateral leg weakness and numbness. In the EHR, please review the patient’s social history and order an MRI of the spine (cervical, thoracic, lumbar) to look for cord compression. When the MRI comes back, it is negative for cord compression, so you re-evaluate the patient and see that the individual can walk without difficulty and no longer has any weakness or numbness. Please discharge the patient with a prescription for pain medication. Order cyclobenzaprine 5mg by mouth every eight hours PRN pain. Dispense 20 tabs.
Scenario 3 – Chest Pain: A 49-year-old patient presents to the ED complaining of chest pain for the past two hours. Pain is substernal and is rated by the patient as being a 10 out of 10. Pain radiates to the left arm and is associated with shortness of breath. The patient indicates the pain is worse with exertion and it feels similar to their last heart attack. The initial EKG shows normal sinus rhythm with non-specific ST-T wave abnormalities. In the EHR, place and order for the following labs:
- CBC
- Chemistry
- Troponin
- Portable Chest X-ray
Also place an order for aspirin 325mg PO and nitroglycerin 0.4mg SL. Some time later, the nurse informs you that the patient’s blood pressure is 90/60. You are going to cancel the nitroglycerin and, in the meantime, the troponin test comes back and is 0.823 (elevated). Please place an order for the following:
- Heparin drip 4000 unit bolus and continuous drip per weight-based protocol
- Troponin test to be repeated in two hours
Finally, please admit the patient to telemetry.
Scenario 4 – Abdominal Pain: A 26-year-old male presents to the ED complaining of abdominal pain and nausea. After a physical exam, you find his pain is focused in the right, lower quadrant of the abdomen and you are concerned it may be appendicitis. Order the following for your patient:
- Ondansetron 4mg IV
- Morphine 4mg IV
- CT Scan with IV and oral contrast
When the CT scan comes back, it is normal and the patient is feeling better and is able to tolerate food and water. Please discharge the patient with a prescription for Ondansetron Q8 hours PRN nausea and Tylenol 500mg PO to be taken every four to six hours PRN pain.
Scenario 5 – Asthma: A 20-year-old woman presents to the ED with shortness of breath and chest tightness symptoms that are consistent with her asthma. She appears to be in mild discomfort but states she is taking her medication as prescribed. On physical exam, the patient has bilateral wheezes and a respiratory rate of 22. Her oxygen saturation is 91 on room air. In the EHR, place an order for the following:
- Nebulized albuterol 2.5 mg X three treatments continuous for the next hour
- Order prednisone 60mg PO
You are now going to review her medical history and outpatient medications to determine if she has been taking them. Lastly, you decide to discharge the patient with a prescription for the following:
- Prednisone taper 60mg reduced by 10 mg every two days for 12 days
- Albuterol (MDI) two puffs Q four to six hours PRN dyspnea; (dispense) one inhaler
- Flu-tic-a-sone inhaled 220mcg Q12 hours; dispense one inhaler
Scenario 6 – Sepsis: The patient is an 83-year-old male with an altered mental status. He arrives from the local nursing home via ambulance. The patient has been having a productive cough for two days and a fever. His initial tests show pneumonia on chest X-ray. Use the EHR to review his vitals and labs page. From the EHR, order the following:
- Normal saline at 30cc/kg bolus
- Piperacillin/tazobactam using renal dosing 2.25g IV
- Lactic acid test
Following completion of the IV fluids, the patient’s blood pressure is 76 over 48 so you order the following:
- Norepinephrine at 0.1mcg/kg/min IV continuous
- Repeat lactic acid two hours from now
Finally, you decide to admit the patient to [INSERT LOCATION].
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