Study: EHR, paper workarounds may lead to efficiencies
Workarounds identified during the outpatient consultation management process, first studied two years ago, continue to challenge EHR-based ambulatory consultation systems, according a study in the July 2011 issue of the International Journal of Medical Informatics.
However, close scrutiny of these workarounds can lead to health IT improvements, stated researchers in "Paper Persistence, Workarounds, and Communication Breakdowns in Computerized Consultation Management." The study is a follow-up to pilot research published in the September 2009 issue of the same journal.
In the 2011 study, Jason Saleem, Ph.D., of the Health Services Research and Development Center on Implementing Evidence-Based Practice at the Richard L. Roudebush VA Medical Center in Indianapolis, and colleagues identified several examples of paper persistence, as well as "shadow processes and tools," communication breakdowns and redundancies in computerized consult management.
“We found, for example, that unless the specialist took the step of indicating the primary care physician should get a notification, or view alert, through the EHR, the referring physician may not know that the results of the consultation were available,” wrote Saleem, a Regenstrief Institute investigator.
In addition, it was not uncommon for specialists to write findings on a piece of paper, despite the risk that medical orders would not be entered into the EHR, potentially creating gaps in documentation or, if entered, producing unverified medical orders put in by someone other than the ordering provider.
The researchers conducted ethnographic observation and semi-structured interviews in nine specialty clinics and three primary care clinics in a large, tertiary Veterans Affairs Medical Center (VAMC). They also performed a national-level query of "electronic error and enhancement requests" related to the consult package in the VA’s EHR, Computerized Patient Record System (CPRS), submitted over a five-year period from 2005 to 2009.
Two researchers recorded the observable interactions and interview responses of 16 healthcare workers related to their work with consultations. Two separate coding schemes were applied to both the observational and the interview data. Participants had an average of 14 years of VA experience and an average of 10 years of experience with CPRS, which was implemented in 1998.
In addition to breakdowns and redundancies, an analysis of enhancement requests for the consults also revealed three broad needs related to reporting, configuration or customization and user interface enhancements, the authors wrote. “Our findings were organized using the sociotechnical systems framework. For example, understanding why clinicians rely on paper-based workarounds (poor integration of the social and technical subsystems) gives us a guide for how to design an enhanced consult package.”
Likewise, external contextual pressures, such as patient volume and performance measurement, highlight how clinicians have developed ‘shadow’ processes to track large numbers of pending consults to make sure none fall through the cracks. Thus, enhanced tracking capabilities need to be considered for an improved consult management clinical information system.
“Our findings help illuminate current challenges to the consult management process and provide a platform to design an informatics tool better integrated with clinical needs and workflow to support clinicians in the delivery of quality medical care,” stated Saleem and colleagues.
The authors noted that limitations of the study should be taken into consideration when interpreting results. “Observation and interview data were based from one major VAMC; including other VA hospitals may have provided a richer understanding of the findings reported in this paper even though the enhancement request query was a national sample,” they wrote.
“Understanding the challenges to the current consult management process is important to help design enhanced informatics tools integrated into workflow to support coordination of care and tracking of consults requests,” the authors concluded.
However, close scrutiny of these workarounds can lead to health IT improvements, stated researchers in "Paper Persistence, Workarounds, and Communication Breakdowns in Computerized Consultation Management." The study is a follow-up to pilot research published in the September 2009 issue of the same journal.
In the 2011 study, Jason Saleem, Ph.D., of the Health Services Research and Development Center on Implementing Evidence-Based Practice at the Richard L. Roudebush VA Medical Center in Indianapolis, and colleagues identified several examples of paper persistence, as well as "shadow processes and tools," communication breakdowns and redundancies in computerized consult management.
“We found, for example, that unless the specialist took the step of indicating the primary care physician should get a notification, or view alert, through the EHR, the referring physician may not know that the results of the consultation were available,” wrote Saleem, a Regenstrief Institute investigator.
In addition, it was not uncommon for specialists to write findings on a piece of paper, despite the risk that medical orders would not be entered into the EHR, potentially creating gaps in documentation or, if entered, producing unverified medical orders put in by someone other than the ordering provider.
The researchers conducted ethnographic observation and semi-structured interviews in nine specialty clinics and three primary care clinics in a large, tertiary Veterans Affairs Medical Center (VAMC). They also performed a national-level query of "electronic error and enhancement requests" related to the consult package in the VA’s EHR, Computerized Patient Record System (CPRS), submitted over a five-year period from 2005 to 2009.
Two researchers recorded the observable interactions and interview responses of 16 healthcare workers related to their work with consultations. Two separate coding schemes were applied to both the observational and the interview data. Participants had an average of 14 years of VA experience and an average of 10 years of experience with CPRS, which was implemented in 1998.
In addition to breakdowns and redundancies, an analysis of enhancement requests for the consults also revealed three broad needs related to reporting, configuration or customization and user interface enhancements, the authors wrote. “Our findings were organized using the sociotechnical systems framework. For example, understanding why clinicians rely on paper-based workarounds (poor integration of the social and technical subsystems) gives us a guide for how to design an enhanced consult package.”
Likewise, external contextual pressures, such as patient volume and performance measurement, highlight how clinicians have developed ‘shadow’ processes to track large numbers of pending consults to make sure none fall through the cracks. Thus, enhanced tracking capabilities need to be considered for an improved consult management clinical information system.
“Our findings help illuminate current challenges to the consult management process and provide a platform to design an informatics tool better integrated with clinical needs and workflow to support clinicians in the delivery of quality medical care,” stated Saleem and colleagues.
The authors noted that limitations of the study should be taken into consideration when interpreting results. “Observation and interview data were based from one major VAMC; including other VA hospitals may have provided a richer understanding of the findings reported in this paper even though the enhancement request query was a national sample,” they wrote.
“Understanding the challenges to the current consult management process is important to help design enhanced informatics tools integrated into workflow to support coordination of care and tracking of consults requests,” the authors concluded.