1. The Rhetoric and Economics of User
Attention in EHR Clinical
Documentation
In a Manner of Speaking…..
Susan Rauch, Ph.D.
Texas Tech University | susan.rauchttu@gmail.com
Conference: Transatlantic Connections Medical Humanities
Bundoran, Ireland | January 11, 2017

2. 2© Duarte, Inc. 2014
+ EHR decision –making
+ Technology Functionality
+ Transaction Hazards
+ Common User Challenges
+ EHR Literacy
+ Rhetorical Value of Clinical
Narrative
+ Economics of Attention
+ Rhetoric of Health and
Medicine
+ Applied Rhetoric
+ Transaction Hazards in
e-Narrative
+ Sociotechnical Systems
Theory (STS) for HIT
+ HITECH/Meaningful Use
+ Economics of Attention
(Rhetorical approach to
economics theory)
+ Applied Rhetoric (Text
production and consumption)
+ STS Theory (HIT Model)
RESEARCH PRESENTATION OVERVIEW
+ Allied Health Professional
+ Industry Experience
+ Personal Experience
+ Graduate Research
+ Hospital Research
​My Research
Journey
​Research
Questions
​Literature
Review
​Theoretical
Frameworks
01 02 03 04 05
+ Printing and Projecting
Slidedocs
+ Distributing Slidedocs
+ Case Study:
From Cinematic to Slidedoc
+ Spread Big Ideas With
Slidedocs
​Research
Methods
+ Scarcity of Attention
+ Alert Fatigue
+ Charting by Exception
+ Automated Technology
+ Training Initiatives
+ UX Research
+ Interviews/Observations
+ Contextual Analysis
+ 3D/8D Assessment Models
​Conclusion and
Next Steps
06 07
​Key Findings

3. 3© Duarte, Inc. 2014
Allied Health
Professional: Dental
Graduate School:
MA English
MA Tech Comm
Allied Health:
Transcriptionist, Editor,
Marketing Research
4-yr Study
Economics of User Attention
EHR Clinical Documentation
Graduate School:
Ph.D. TCR
MY RESEARCH
JOURNEY
01

4. MY RESEARCH JOURNEY:
Evolution of Clinical and eHealth Documentation
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS (HPI)
PAST MEDICAL HISTORY (PMH)
MEDICATIONS
ALLERGIES: PENICILLIN
FAMILY HISTORY: Father high BP. Mother basal cell carcinoma.
SOCIAL HISTORY: Nonsmoker. Alcohol 1 drink q.d.
REVIEW OF SYSTEMS
General: no fever, no chills, no sweats
Cardiovascular
ENT
Respiratory
GI
Neuro
GU
PHYSICAL EXAM
Vitals: BP 108/58, HR 72, RR 12, O2 95%.
HEENT:
Neck
Cardio: No murmur
Skin
LABS
WBC
RBC
EKG
PROBLEM LIST (current symptoms/reason for visit)
01

5. Images: Hosp. B Usability Testi Plan
LetDoctorsBeDoctors
MY RESEARCH JOURNEY:
Evolution of Clinical and eHealth Documentation
01

6. RESEARCH QUESTIONS
1. How does EHR technology influence health professionals’ decision-making
regarding clinical documentation best practices (and challenges) that affect
the overall integrity of the EHR clinical narrative?
2. In what way does the accessibility and functionality of EHR technology in the
workplace influence EHR-end users’ communication practices?
Sub-Questions
? Common challenges end-users encounter in EHR clinical documentation leading to
transaction hazards in EHR narratives?
? How can technical-health communicators add value in the improvement of eHealth
documentation practices that affect the capture and interpretation of EHR-
generated narratives?
02

7.  Economics of Attention: Rhetorical approach to attention economics theory.
Competition for attention as a scarce resource. How style in electronic
documentation attracts or regulates attention. (Lanham)
 Sociotechnical Systems: User challenges associated with EHR technologies.
Approach to users workflow and interaction with health information technologies
(HIT). (Sittig and Singh)
 Applied Rhetoric: Rhetorical and competitive value of electronic text. How technical
communicators create value. (Carter)
LITERATURE REVIEW
 Rhetoric of Healthcare and Medicine: “Strategies that influence medical authorship
[in illness narratives].” (Segal) “How we interpret and receive texts as rhetoric.”
(Heifferon and Brown)
 Transaction Hazards: EHR errors of omission and commission (Yackel and Embi)
Clinicians challenges with electronically written communication (Johnson et al.)
LITERATURE REVIEW & APPLIED THEORETICAL FRAMEWORKS
03 04

8. RESEARCH METHODS
Data Collection
Interviews: 21-34 questions (dependent on specialty)
 36 Health Professionals, 2 Hospitals (NW and Central Texas)
Survey: 11 Questions
 42 Responses
 Email/Qualtrics Distribution: HFMA and ACDIS*
Contextual-Rhetorical Analysis: EHR Testing Event
 10 Usability Heuristics for EHR Task Performance (Nielsen)
 Defined Verbal/Nonverbal Rhetorical Units of Value (Blythe)
*HFMA: Health Finance Management Association Membership email LISTSERVE
*CDIS: Association for Clinical Documentation Improvement Specialists Membership email LISTSERVE05

9. RESEARCH METHODS
*HFMA: Health Finance Management Association
*CDIS: Association for Clinical Documentation
Improvement Specialists
QUALITATIVE
STUDY
Contextual-Rhetorical
Analysis
Observation: EHR
Testing Event
10 Usability Heuristics
for EHR Task
Performance (Nielsen)
Defined
Verbal/Nonverbal
Rhetorical Units of Value
(Blythe)
SURVEY
11 Questions
42 Responses
Qualtrics Surve Tool
HFMA and ACDIS* Listserve
INTERVIEWS
1-34 questions
36 Health Professionals
2 Acute Care Hospitals
(NW and Central Texas)
Coding: N-Vivo and Doc
Tools
Saldana’s Qualitative
Methods
05

10. RESEARCH METHODS: KEY FINDINGS
Crossweaving (overlap) of 4 emergent themes
06

11. AUTOMATED TEXT AND TECHNOLOGY
ARE YOU PAYING ATTENTION?
06

12. KEY FINDINGS
06
Other Comparative Studies on Safety Alerts
and Alert Fatigue: 1 Month Frequency Stats
ICU CPOE
Monitors

13. HOW ATTENTION STRUCTURES
COMPETE FOR ATTENTION
VideoImages: Cerner Store
EHR is Health
EHR is ROI
EHR is Narrative
ICD is Diagnosis (or Health)
ICD is ROI
ICD-9 463 is acute tonsillitis
ICD-10CM J18.9 is pneumonia
KEY FINDINGS
06

14. Workflow Models for EHR Narrative Research
RECOMMENDATIONS AND FUTURE RESEARCH

15. 8D Sociotechnical Model – Sittig And Singh
Measurement for Sociotechnical Challenges in HIT Systems
Hardware and Software
Infrastructure that refers to equipment used to power, support,
and operate clinical applications
Clinical Content
Textual or numeric data and images that constitute “language of
clinical applications.”
Human Computer Interface
All aspects of the computer that users can see, touch, and hear, as
they interact with it.
People
Everyone who interacts in some way with the system, from
developer to end user including potential patient-users.
Workflow Communication
Processes and steps involved in assuring that patient care tasks are
carried out effectively.
Internal Organization Features
Includes policies, procedures, and cultural considerations
External Rules and Regulations
External forces that place constraints on the design, development,
implementation, use, and evaluation of HIT.
Measurement and Monitoring
Process of measuring and evaluation (quality assurance and
control) both intended and unintended consequences of HIT
implementation and use.
WORKFLOW MODELS FOR EHR NARRATIVE RESEARCH

16. Handout: http://www.slideshare.net/SusanRauch1/rauch-transatlantic-connections-med-humanities-handout
WORKFLOW MODELS FOR EHR NARRATIVE RESEARCH

17. CONCLUSION AND NEXT STEPS
 Interviews: Talk to Physicians! And EHR vendors/TC’s – To better understand best
practices in EHR usability/documentation decision-making.
 Usability/UX Test Training Initiative: Academic SIM EHR as clinician training tool at
point-of-care.
 Usability/UX Testing: Observation and Mouse tracking task performance at point-
of-care (usability software). Optimally with/comparing different EHR
vendor/hospital systems.
 Observation of EHR Development: Text and Technology. Role of technical
communicator.
 Rhetorical Analysis: EHR vendor competition; arguments in provider EHR decision-
making.
07

18. NEXT STEPS: FUTURE RESEARCH
Recommend Training Initiatives
To improve EHR digital literacy and communication practices
Improve on scarcity of attention to text and technologies
Text & Technology: Applied 3D and 8D Assessment Models
To assess the competition of and sociotechnical challenges with EHR text and
technology re: decision-making processes of healthcare providers and users
Evaluate rhetorical value of competitive attention structures e.g. automated
technology, alert fatigue, coding structures
Assess rhetorical value of TC decision-making in the development and distribution of
EHR systems (production-reception-social circumstance)
Data Exchange between hospital facilities (presently not universalized - proprietary)
07

19. More About Me:
Susan Rauch, Ph.D.
susan.rauchttu@gmail.com
susanrauch.wordpress.com

20. MY SCHOLARSHIP
PUBLISHED ARTICLES AND WORKS IN PROGRESS
Accepted
"The Accreditation of Hildegard von Bingen as Medieval Female Technical Writer."
Journal of Technical Writing and Communication 42.4 (2012): 393-411.
Non-Refereed
“Rhetoric of Health and Medicine Wiki.” Contributing collaborator, co-author and
editor.
“Healthcare Literacy Guide for Aged and Disabled.” Texas State University-San
Marcos. Service-Learning Initiative. (digital health promotion guide)
Under Review
“Annotating Time and Place: Mapping the Collective and Cultural Memory of
Anna Coleman Ladd During the Great War.”
“IRB Problems and Solutions in Health Communication Research.” (co-authored by
Carie King, Kristin Bivens, Erin Pumroy, Susan Rauch, Amy Koerber)
In Preparation
“Dialogues from an Online Nursing Community: Identifying Barriers, Overcoming
Ethical Challenges of Nurses with Disabilities” (
“It’s All in the Literature: Disability and Public Health Perceptions of Bohemian and
Czech Immigrants in 19th through 20th Century Midwest America
“The Rhetoric and Economics of User Attention in EHR Clinical Documentation
and Usability Best Practices”
“Educating the Educator: A Parent’s Perspective of Psychopharmacology and
Tourette Syndrome
“Evaluating the role of disability studies and assistive communication technologies in
the teaching of technical communication and instructional design.”
“Metaphorically and Medically Speaking… The Rhetoric and Economics of Attention
of Journey Metaphor in eHealth Management Service Organizations’ White
Papers.” (written and visual strategies in argumentation)
PRESENTATIONS: NATIONAL AND INTERNATIONAL
“In a Manner of Speaking: Using Rhetoric and Economics of User
Attention in the Study of eHealth Clinical Narrative Constructio.”
Transatlantic Connections: Equality Emerging: Session: The Field of
Medical Humanities' Influence on Healthcare Access and Delivery.
Bundoran, Donegal,
Ireland Drew U.
2017
“Rhetoric and Economics of User Attention in the Documentation of
EHR-generated Clinical Narratives.” ATTW. Graduate Award
Recipient.
Houston, TX 2016
“Rhetoric and Economics of eHealth Records: The risk and value of
economizing language in the digitization of patient narratives.”
Conference on College Composition and Communication (CCCC).
Tampa, FL 2015
“Out of the Classroom, Into the Workplace: Simulation and Assimilation of
eHealth Curricula.” CCCC.
Indianapolis, IN 2014
“Nurses with Disabilities: Identifying Barriers, Overcoming Ethical
Challenges (Analyzing Dialogues in an Online Nursing Community),”
4th Annual Conference in Values in Medicine, Science & Technology.
Dallas, TX
U. of North Texas
2014
“Annotating Time and Place: A collective and cultural memory of the Great
War from the Anna Coleman Ladd Papers: American Red Cross Studio
for Portrait-Masks File, 1914-1925,” War Memories Conference.
Rennes, France
EU of Brittany
2014
“Corpus and Presenter Tool: Identifying trends and transitions in page
design and genre in Late Medieval through Early Modern medical
texts,” 48th
International Congress of Medieval Studies
Kalamazoo, MI
WMU.
2013
“The Paston Letters (1422-1509): A Prosopography of Late Medieval to Early-
Modern Friendship,” 46th
International Congress of Medieval Studies.
Kalamazoo, MI
WMU
2011
REGIONAL INVITED TALK
Dept. of Psychology and Special Education. School of Education. Topic:
“Educating the Educator: A Parent’s Perspective of
Psychopharmacology and Tourette Syndrome.”
San Marcos, TX
TxState U.
2011

21.  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.
 Segal, Judy, 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.
 Scott, Blake; Segal, Judy Z.; and Keranen, Lisa. "The Rhetorics of Health and Medicine: Inventional
Possibilities for Scholarship and Engaged Practice." Poroi 9, Iss. 1 (2013): Article 17.
 Wachter, Bob. Professor and Interim Chairman of the Department of Medicine at the University of California,
San Francisco (UCSF) Aug. 2015. IHI.org
 Derkatch and Segal Realms of Rhetoric in Health and Medicine
 Cerner Store. Cerner.com. 2016.
 AllScripts. AllScripts.com. 2016
CONSULTED SOURCES

22. EXTRA SLIDES

23. ATTENTION STRUCTURES:
AUTOMATED TEXT AND TECHNOLOGY
“How we pay attention
to the world of [digital]
information and hence
what use we can make
of it” (Lanham 14).

24. PURPOSE OF STUDY: So what?
 To understand the rhetorical value of human attention in eHealth
clinical documentation due to information overload.
 Assess how and why clinicians’ attention is challenged by EHR
technologies that lead to transaction hazards in EHR-generated clinical
narratives.
 Explore end-user perspectives about EHR clinical-documentation
practices

25. CONTEXUAL-RHETORICAL ANALYSIS:
Key Findings – Task Performance
Image Source: AllScripts Maternity
Attention Structures: Verbal/nonverbal signals (means of expression) in
the EHR narrative constructs

26. Attention Structures:
What is Alert Fatigue?
When clinicians become desensitized to safety alerts, and as a
result ignore or fail to respond appropriately to such warnings”
(AHRQ 2015)
“The near-constant, often-annoying profusion of system alerts”
such as audio and visual warnings that pop up in the screen”
(Miliard 2015).

27. AUTOMATED TEXT AND TECHNOLOGY:
Computerized Pop Up (Examples)
2. Rx Safety Alert
Images: CabellHuntingtonHospital
1. Communication Type Menu
(Noted in Task Performance
Results)
Image: Cerner Store

28. AUTOMATED TEXT AND TECHNOLOGY:
Usability Test Frequency of Safety Alerts
14x’s
30 min
From: UX EHR Testing Event: Task Performance/Contextual-Rhetorical Analysis

29. LIMITATIONS OF RESEARCH
 No Physician Participation
 Unable to Observe EHR Navigation at
Point-of-Care
 Communication difficulties with EHR vendors
 Small Survey Population