ATTW 2016 Graduate Research Award Recipient. Overview of dissertation.

1. Susan Rauch, Ph.D. Candidate
Texas Tech University | Technical Communication and Rhetoric
RHETORIC & ECONOMICS OF USER ATTENTION:
eHealth Record Systems Management, Usability,
and Clinical Documentation Practices
TEXAS TECH UNIVERSITY
ATTW 2016 Graduate Research Award Presentation

2. AUTOMATED TEXT AND TECHNOLOGY:
ARE YOU PAYING ATTENTION?

3. An unnecessary alert is
DANGEROUS…
It make it that much
less likely you will pay
attention to the next
one
Copyright © 2015 Institute for Healthcare Improvement (IHI.org)

4. AUTOMATED TEXT AND TECHNOLOGY:
ATTENTION TO EHR SAFETY ALERTS
UCSF Medical Center (Wachter 2015)
• Physicians: 30,000 (just computerized pop-up boxes)
• Pharmacists: 160,000
• Computers (HR, BP, Ox monitors): 2.5 million
AHRQ 2014 Study ICU CPOE Monitors
• 2 million alerts=187 warnings/patient/day
Safety Alerts: 1 Month Frequency Stats

5. AUTOMATED TEXT AND TECHNOLOGY:
ATTENTION TO EHR SAFETY ALERTS
Computerized Pop Ups

6. PURPOSE DISSERTATION RESEARCH
 To understand the rhetorical value of human
attention in response to attention structures in
eHealth clinical documentation.
 Assess how and why clinicians’ attention is
challenged by EHR technologies that lead to
transaction hazards in EHR-generated narratives.
 Explore end-user perspectives regarding EHR clinical
documentation practices and EHR functionality,
including the stabilizing and destabilizing forces e.g.
attention that enable or disable the EHR narrative
constructs.

7. METHOD AND DESIGN
 Research Method and Design
•Contextual-Rhetorical Analysis: EHR UX Testing Event:
Task Performance and Interface Design
•Interviews: 36 health professionals, 2 hospitals
•Survey: 42 responses from HFMA and ACDIS experts*
 Applied Theoretical Frameworks and Assessment
Models
•Economics of Attention (Richard Lanham)
•8D Sociotechnical Systems Model for HIT (Sittig and Singh)
•3D Model in Applied Rhetoric (Joyce Locke Carter)
•10 Heuristics for Usability Testing (Nielsen)
*HFMA: Health Finance Management Association Membership
*CDIS: Association for Clinical Documentation Improvement Specialists Membership

8.  Economics of Attention: Competition for attention as a
scarce resource. How style in electronic devices attracts
or regulates attention. (Lanham)
 Rhetoric of Healthcare and Medicine: “Strategies that
influence medical authorship.” How we interpret and
receive texts as rhetoric.” (Segal; Heifferon and Brown)
 Applied Rhetoric: Rhetorical and competitive value of
electronic documents.(Carter)
 Sociotechnical Systems: User challenges with EHR
technologies e.g. workflow and written communication
practices. (Sittig and Singh)
SUPPORT LITERATURE

9. KEY RESEARCH FINDINGS:
INTERVIEWS

10. ATTENTION STRUCTURES:
AUTOMATED TEXT AND TECHNOLOGY
 Charting by Exception
 Digital Overload:
Buttons and Icons
How we pay attention to the world of [digital]
information and hence what use we can make of it.
(Lanham 14)

11. ATTENTION STRUCTURES:
AUTOMATED TEXT AND TECHNOLOGY
Charting by Exception (CBE): When technology
supersedes the act of critical thinking.
 Recall: Cheating through the documentation
process e.g. repeating the use of Function keys
 Communication Type: Dropdown Menu with pre-
selected norms. Uses visual color cues to suggest
answers. If incorrectly chosen, the narrative is
compromised.
Interview Participant: The right “Communication
Type” selection . . . determines the electronic routing.

12. Attention Structures:
Digital Information Overload
Video
Buttons and Icons
Images: Cerner Store

13. Navigation
Menus, Buttons,
and Icons
Attention Structures:
Digital Information Overload
Images: UMC Usability Test Plan

14. RECOMMENDATIONS FOR FUTURE
RESEARCH
Improved Digital Literacy: Academic EHR SIM Models for
Workplace Point-of-Care Clinician Training
 Observations UX testing at point-of-care to evaluate
scarcity of attention and rhetorical value of attention
structures
• Mouse tracking and usability software to screencast record
clinicians EHR documentation task performance
• Observe EHR Developers in Document Design/Style
 Recommended Assessment Tools
• Assessment models (3D and 8D) to study strategies in economics
of attention that influence medical authorship and eHealth
documentation practices (see handout)
• 10 heuristics for evaluating interface design

15. ?’s

16.  Carter, [Joyce] Locke, ed. Market matters: Applied rhetoric studies and free
market competition. Hampton Press (NJ), 2005.
 Heifferon, Barbara, and Stuart Cameron Brown, eds. Rhetoric of healthcare:
Essays toward a new disciplinary inquiry. Hampton Press, 2008.
 Lanham, Richard A. The economics of attention: Style and substance in the age
of information. University of Chicago Press, 2006.
 Nielsen, Jakob, and Rolf Molich. "Heuristic evaluation of user
interfaces."Proceedings of the SIGCHI conference on Human factors in
computing systems. ACM, 1990.
 Segal, Judy. Health and the rhetoric of medicine. SIU Press, 2005.
 Sittig, Dean F., and Hardeep Singh. "A new sociotechnical model for studying
health information technology in complex adaptive healthcare systems."Quality
and Safety in Health Care 19.Suppl 3 (2010): i68-i74.
 Wachter, Bob, Professor and Interim Chairman of the Department of Medicine at
the University of California, San Francisco (UCSF) Aug. 2015. IHI.org
REFERENCES