Study: Clinicians using workarounds when operating EHRs
Wednesday, March 13, 2019
The majority of U.S. hospitals have implemented electronic health records (EHRs). While the benefits of EHRs have been widely touted, little is known about their effects on inpatient care, including how well they meet workflow needs and support care.
Despite the proliferation of the technology, there appears to be a high degree of variance in the ways care teams use EHRs during morning rounds. There are a high number of workarounds clinicians employ at critical points of care. Additionally, the EHRs are not used for information sharing and frequently impede intra-care team communication.
These points are the results from a new study, "Assessing EHR use during hospital morning rounds: A multi-faceted study," published by PLOS.org. Ultimately, the research shows that electronic health record system design and hospital room settings "do not adequately support care team workflow."
"Gaps between EHR design and the functionality needed in the complex inpatient environment result in lack of standardized workflows, extensive use of workarounds and team communication issues," researchers said. "These issues pose a threat to patient safety and quality of care. Possible solutions need to include improvements in EHR design, care team training and changes to the hospital room setting."
Originally, EHRs were intended to improve some aspects of care, including patient safety, clinical decision-making and information exchange; and were supposed to be a cost-effective tool for improving quality of care. For many organizations, challenges remain, including prolonged documentation time, interference with communication, usability difficulties, lack of cognitive support, failure to support the clinical workflow and low user satisfaction.
"There is little evidence that EHRs are improving the quality of inpatient care," researchers said. "Even though efficiency seems to have improved, usability appears to be mixed at best and EHRs' ability to provide proper support for care team workflow has not yet been established. Anecdotal reports suggest that EHRs may be contributing to clinician burnout."
The study was conducted at a major teaching hospital in New England with more than 700 participants. The hospital implemented Epic’s EHR across all units.
Most clinicians said they always use the EHR before entering the patient’s room, but only sometimes in the room. Before rounds, most clinicians said they always use the EHR before entering the patient’s room, but only sometimes when in the patient’s room.
When asked about EHR use after leaving the patient’s room, clinician types varied in their responses. More than 40 percent of the attending clinicians and 50 percent of the residents reported using the EHR after leaving the patient’s room sometimes, whereas 50 percent of the interns and nearly 54 percent of the PAs reported always using the EHR after leaving the room, researchers found.
Workarounds are nonstandard procedures typically used because of deficiencies in system or workflow design. Workarounds that were documented during observations and interviews included extended use of handwriting, emails and verbal discussions. Printouts of patient summary reports were used to add information from the EHR in handwriting, such as vital signs and recent lab results.
"We also observed various workarounds during the handoff process, both before and after morning rounds. Email and verbal discussions were used to convey important information and overnight events regarding patients," researchers said. "For example, updates on events that took place during rounds monitoring and debriefing after rounds were carried out either verbally or through email."
Most clinicians said that they visually share EHR information sometimes, and when asked if EHR use interrupts care team communication, responses varied among clinician types. "Most attending clinicians and interns responded that EHR use never interrupts care team communication, while most residents and PAs responded that it does sometimes," the study found.
Most clinicians also said that they find EHRs useful for synchronizing the care team regarding patients and for teaching purposes sometimes but attending clinicians’ responses on the EHR’s role in efficiency during rounds were inconsistent, with nearly half of them reporting that it is useful only sometimes, and the other half reporting that it is useful most of the time. Residents said they find the EHR useful for efficient rounding only sometimes, whereas most interns and PAs find it useful most of the time.
"Our findings indicate that the EHR is not regularly used in patients’ rooms as part of the workflow. When it is used in the room, verbal and visual sharing of EHR information among care team members are rare. Screen location, screen size and the available technology do not facilitate a shared view of the EHR. Recognizing the importance of effective communication and teamwork for delivery of high-quality and safe patient care, several medical team training programs have set out to enhance communication between team members."
Some workarounds, such as handwritten notes, were used as a cognitive aid for clinicians. Others were used because of a lack of system support.
Studies have shown that the format and layout of paper records are critical to the clinicians’ ability to search, read and assess relevant information. The ability to markup important findings is important to the cognitive processing of clinical information and could be lost when working directly in the EHR.
Researchers suggested three solutions to the workflow issues:
1. EHR design changes and interface improvement:
It would be beneficial to consider different ways of visualizing data to prevent information overload and make the system easy to use in real time in the patient’s room.
There is need to better integrate mobile devices that are easy to carry around between different floors/units in the hospital. It is equally important to consider integrating complementary HIT tools that support clinicians’ needs and workflow, such as handwriting recognition capabilities on mobile devices.
2. Hospital room adjustments and redesign:
The current study site hospital room setting does not provide the infrastructure for sharing information between care team members or with the patient. Possible approaches include whiteboards that will allow projecting EHR data in the room, and positioning the bedside computer so that it does not require the clinician to turn her/his back toward other clinicians in the room and the patient.
3. Care team training programs that consider EHR use during rounds:
Such programs need to address how the EHR can be better integrated into the workflow in ways that do not impede team communication, especially during rounds and promote EHR use for improving communication and information sharing between care team clinicians.
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