An Exploratory Study to Evaluate the Technological Barriers and Facilitators for Pediatric Behavioral Healthcare in Emergency Departments

Abstract

The objective of this study was to identify the technological barriers and facilitators of safe and effective pediatric mental and behavioral health care in emergency departments. The study, which involved a total of 4 participants, employed observational studies and semi-structured interviews to gather data from medical professionals across two hospitals. The data collected from the interviews were analyzed for themes relating to the use of technology, including factors that enable or impede safe and effective care for pediatric mental and behavioral health patients. Barriers included challenges related to software usability, inadequate training on newer software features, and concerns regarding the quality of service delivered by third-party vendors. Facilitators comprised the accessibility of clinician’s notes, effective tools and technologies for clinician and patient safety, and efficient communication tools.

Introduction

In the United States, mental and behavioral health conditions affect one in six children aged 2-8 years, and studies indicate that over half a million children a year present to an emergency department (ED) with a behavioral health problem (Bitsko et al., 2022; Sheridan et al., 2015). Emergency medicine clinicians are required to expeditiously evaluate, diagnose, treat, educate, and discharge patients. As a result, various technologies, such as electronic medical records (EMR), tele-health, and patient portals, are increasingly being employed to enhance the efficiency, safety, and effectiveness of care processes in the ED (Ramsey et al., 2018; Rao et al., 2012).

Wooldridge et al. (2020) identified several work system barriers in inpatient care transitions within and outside general ED settings, including anticipating reduced staffing resources, space constraints that lead to crowding, inadequate staffing, communication issues, usability, and other technological issues. Identifying and systematically analyzing these system barriers and facilitators is critical to comprehensively understanding the role of technology in supporting healthcare providers in their caregiving tasks. Technology-enabled systems may pose usability and interoperability issues, such as the design of Electronic Medical Records (EMR) that does not support the workflow of clinicians, excessive documentation, non-integration of health information technology devices compromising patient safety, leading to hazards and medical errors (Staggers et al., 2018; Agnisarman et al., 2017). Pediatric patients have several unique characteristics and are vulnerable to medication dosing errors due to EMR usability issues (Ratwani et al., 2018). Technological issues with electronic discharge communication tools such as inadequate information, integration challenges, excessive documentation, and lack of workflow support strain healthcare workers, potentially contributing to burnout (Agboola et al., 2016; Ratwani et al., 2018; Rogers et al., 2021a; Rogers et al., 2021b). Although studies have been conducted in general ED settings, minimal research has been carried out to identify technological barriers and facilitators for pediatric behavioral health care in the ED, a critical aspect for designing safe and effective care for this vulnerable population. Therefore, this study aims to identify the barriers and facilitators created by technology in the ED when providing care to pediatric patients with mental and behavioral health conditions.

Method

A qualitative approach, combining interviews and observational studies, was employed to identify the technology related barriers and facilitators within the ED work system. Participants in different roles were recruited through purposive sampling across two hospitals. First, researchers conducted active observational studies in two hospitals to understand how technology was being used in ED settings in the context of mental and behavioral health care. Subsequently, we employed a semi-structured interview protocol to conduct face-to-face or remote interviews with 4 healthcare providers across various roles in their respective hospitals. Specifically, interviews were conducted with assistant nurse manager, charge nurse, security accounts manager and patient safety specialist to better understand the factors that may contribute to or hinder the caregiving process.

The transcriptions of the audio-recorded interviews were done using Otter.ai. Next, the interview transcripts were coded into themes using Atlas.ti. The codebook and coding methodology was constructed using the Systems Engineering Initiative for Patient Safety 2.0 (SEIPS) framework focusing on barriers and facilitators related to the physical environment, tools and technology, organization, people, and tasks. The coders developed and refined the codebook, code definitions, and coding methodology and finalized 190 codes. Later, the group discussed the codes for consensual agreement and eliminated any discrepancies to identify barriers and facilitators. Inter-rater reliability was measured after each session using the percentage of intercoder agreement. There was high agreement among the researchers, Krippendorff’s α= 0.731. An expert coder with experience in healthcare design and human factors research independently coded 10% of each session to obtain inter-coder agreement. Similar barriers and facilitators were grouped for a thematic analysis to understand factors leading to patient safety.

Results

The observations and task workflow analysis found that patients can enter the ED through three pathways: EMS, walk- in patients, or accompanied by law enforcement agencies. The triage nurse initially assessed patients upon entering the emergency department via walk-in with a parent. A patient entering via EMS or through law enforcement was taken to the ED and triaged by a pediatric ED nurse. The nurse assessed the patient’s risk of self-harm using the Columbia-Suicide Severity Rating Scale (CSSRS), considering certain questions with affirmative answers as indicative of high risk. If the patient was determined to be a high-risk patient with mental or behavioral health issues like suicidal ideation, a ligature-free or low- ligature (where available) room was assigned with a sitter present to observe the patient.

A pediatric physician then completed a medical checkup for clearance and decided on discharge, observational hold, or admission to an inpatient psychiatric unit, working closely with social workers and psychiatrists. Although these procedures slightly varied across the two hospitals, the general process remained consistent, with modifications to the personnel involved due to different hospital policies and staffing models. All two facilities utilized the Epic system for electronic health records and Telmediq for communication with other clinicians. The Epic software was accessible on desktop computers and computer-on-wheels, a mobile workstation that could be transported within the emergency department. All clinicians utilized Epic for documenting patient information during consultations, with physicians employing a handheld speech-to-text device for note-taking. Patients or guardians could view their history using MyChart, and technicians and security personnel used security cameras to monitor pediatric patients.

Hospitals incorporated tele-psych video conferencing with psychiatrists and language interpreting software on iPads to facilitate communication with culturally diverse patients. Hospitals utilized various security communication devices among clinicians for security when dealing with patients with adverse behavioral health conditions like behavioral outbursts including screaming, yelling, aggression or violence towards staff and hurting themselves. Panic buttons were installed on the walls of patient rooms. Another security device that clinicians carry is a wearable panic button called Strongline (Commure, 2023). In the event of emergencies or perceived threat; for example, when a patient poses a threat to clinicians or themselves, activating the panic button alerts individuals within a 40-foot radius and provides the location of the person in distress to security personnel. The security team also uses various systems like walkie-talkies and security cameras that help them manage security events. Clinicians and administrators use a policy management database to search policies relating to various medical procedures. Administrators use an event management system to track, assign, and investigate security events, clinician process efficiencies, and medical errors. These systems help efficiently solve organizational and policy issues in the hospital. Counselors use referral management software to place patients in outpatient facilities.

The researchers observed various technological barriers in this process regarding the usability of Epic, and clinicians did not understand some of its features. Most clinicians preferred to not bring computers or other technology into patient consults, so that they could make eye contact with patients and build rapport. Technology was seen as creating distractions during the interaction with the patient. As a result, clinicians (especially mental health counselors and psychologists) invest extensive time on Epic after consults documenting notes and the medications provided to the patient. This requires them to remember details of the consultation extensively during documentation. Clinicians suggested the availability of a convenient method to chart patient records on Epic without missing out on important information. Hospital staff had to undergo certifications to use Epic. They suggested providing feature specific training on a regular basis would enable them effectively use Electronic Health Record. Clinicians extensively communicated with each other using the Telmediq system and at times, found it difficult to contact the right clinician utilizing the software.

Clinicians mentioned several issues with the language interpreting services, including lack of access, wait times, quality of services, and service providers. However, several clinicians indicated that they used an on-demand translation service using an iPad that enabled them to communicate more effectively with non-English language speakers. Clinicians mentioned significant usability issues with the policy database management system as they had to spend a lot of time finding the required policy they need. Security events, clinician process efficiencies, and medical errors are assigned to quality improvement teams and leadership for further investigation via the event management system. However, security events sometimes remain unresolved due to stakeholder unavailability and oversight. Clinicians mentioned the need for periodic training on tools such as Epic, policy management systems to facilitate learning tools and technologies that enable caregiving.

Clinicians mentioned several facilitators that help them in the caregiving process. A few clinicians mentioned that Epic is easy to use, and they did not have experience with any other EMR. When clinicians can see each other’s notes about a patient, it helped them make informed decisions regarding the care plan for the patient. However, some clinicians did not choose to publish their notes to avoid confusion with the patient’s family. Clinicians felt safe with the strong line system as it notified everyone within a 40-foor radius and did not depend only on security. Security also used devices like walkie- talkies that help them communicate with one another. The use of cameras in the ED and mental and behavioral health unit facilitated patient, clinician, and visitor safety. The event management system facilitated event logging and automatic notification to leadership, enabling their active involvement and engagement. Clinicians mentioned that communication is important to investigate security events, and communications tools such as Telmediq, messages, and emails facilitated effective communication with the leadership. Clinicians preferred using the iPad due to its mobility features for the language interpreting systems in the ED and prefer its use in the other parts of the hospital.

Discussion

Clinicians reported issues with the tools and technologies used in the emergency department while treating mental and behavioral patients. Issues like immediate access to security devices, challenges in using EMR and policy management systems, ineffective clinician communication due to such challenges in Telmediq as finding the right clinician to contact, and inadequate tracking of security events in event management systems hinder the caregiving process. The significant time required to chart patient medical diagnoses and search relevant policies to accommodate patients potentially contribute to clinician burnout. Given clinicians’ extensive use of Epic for documentation purposes, the system design must prioritize ease of use, enabling more efficient charting methods. This approach can potentially minimize clinician burnout and enhance patient safety by reducing errors. While the security measures implemented by hospitals effectively ensured clinician safety during adverse behavioral emergencies, there was a need for more robust and more comprehensive tools to address patient safety from visitors, who might impose a threat to the patients. The security personnel recommended implementing visitor badges with identification pictures, clearly indicating their status as either approved visitors or trespassers through appropriate color coding.

Clinicians expressed a preference for in-person interpreters due to concerns about the quality of service provided by tele-interpreters, which posed a barrier to understanding patient problems and potentially compromised patient safety. Clinicians also reported issues with the tele - interpreter software, which would occasionally malfunction, hindering their workflow. Therefore, the tele-interpreting service encountered two barriers: quality of service from interpreters and software malfunctions, both of which impeded effective communication between patients and clinicians. These challenges highlight the need for a redesign process that addresses these barriers and improves the design of interpreter services. Patient-clinician communication is of utmost importance and needs to be facilitated adequately to support the caregiving process. The policy management tool serves the purpose of informing and updating clinicians about organizational policies. However, clinicians have reported significant usability issues, specifically with the search functionality. They encountered difficulties in searching policies unless they used exact keywords. Consequently, the search mechanism within the tool requires redesigning to enhance usability, enabling clinicians to access policies and save time.

The findings of this study will form the foundation for future research, which will aim to investigate the application of human-centered design to develop and evaluate technology and process interventions to tackle the technological barriers in managing pediatric patients with mental and behavioral health conditions in the ED.