The impact of health IT on workflow
Monday, August 03, 2015
A new report, "Examining the Relationship Between Health IT and Ambulatory Care Workflow Redesign," by the Agency for Healthcare Research and Quality examines the enhanced understanding of the causal relationship between health information technology implementation and ambulatory care workflow redesign; sociotechnical factors and the role they play in mitigating or augmenting health IT’s impacts on workflow; and the workflow impacts of health IT magnified through frequently occurring disruptive events, such as interruptions and exceptions.
The report was conducted across six ambulatory care practices from across the United States, and reviewed health systems that had implemented different health IT products or systems, including an electronic homepage, a standardized message center, computerized provider order entry (CPOE), and electronic prescribing (e-prescribing) to an existing electronic health record (EHR) system.
As part of the study, the attitudes and perceptions of different stakeholders in the participating organizations (e.g., clinicians, clinic staff, IT personnel and executive leaders) were assessed through semi-structured interviews and then through member-checking focus groups.
A total of 120 clinicians and clinic staff participated in the study. The results showed that a number of work and workflow processes were altered after the health IT implementations, including a redistribution of clinicians' and clinic staff's time on different clinical tasks, repurposed usage of workspace, increased level of interruptions, multitasking and off-hours work activities. A majority of these changes appeared to be attributable to two inter-related causes: increased structured documentation requirements and shifted responsibilities among individuals serving different clinical roles.
The agency points out that health information technology and EHR systems have been widely viewed as holding great promise to help cross the quality chasm in the U.S. healthcare system and to bend the curve of ever-rising costs; however, health IT implementations in the U.S. have experienced a range of problems including rollout delays, budget overruns and end-user resistance. Many studies have further demonstrated that successfully deployed systems often failed to generate anticipated results; some were even associated with unintended adverse consequences.
Health IT can create additional work and impact workflow unfavorably by creating inefficiencies or disruptions, the report stated. These impacts are attributable to the changes that health IT implementations introduce to established clinical work processes and workflow.
As pointed out in the report, while the benefits of health IT have been demonstrated, negative findings have also been noted; most of these findings related to the workflow implications of implementing health IT.
"Developing an enhanced understanding of how health IT implementations alter clinical work processes and workflow, in addition to the root causes and consequences of these impacts, is therefore of vital importance. Available studies are scarce, and findings are inconclusive and oftentimes conflicting," the authors of the report note.
Furthermore, methods for studying clinical workflow vary widely as evidence of health IT's impacts on clinical workflow have been "anecdotal, insufficiently supported, or otherwise deficient in terms of scientific rigor."
In each of the participating organizations, a major health IT implementation was scheduled to take place during the study. These organizations were selected, each having a deep interest in using health IT as a key strategy to support practice redesign and quality improvement, and each having multiple ambulatory care practices serving different patient populations in areas with distinct geographic and socioeconomic profiles.
Three ambulatory care practices participated from each of the two organizations. Five of the six participating practices were primary care clinics and implementation of patient-centered medical home (PCMH) models of care were underway at both study organizations at the start of the study.
According to Health Data Management, the study observed that patient interruptions are also common when new health IT is introduced, as documentation requirements demand more computer time for providers, who are therefore spending more time on the computer during patient visits. In those instances, the report finds that the "new health IT has not been adequately integrated into the workflow design, which includes the provider-patient interaction." Moreover, providers in the study often had less time to talk to patients during a visit following the health IT system implementation.
In addition to negative impacts on clinical workflow, the study noted differences in the quantity of interruptions that occurred during pre- and post-implementation of health IT. For instance, clinicians and staff at one clinic experienced a more than threefold increase in the frequency of interruptions following the health IT implementation, while other clinics experienced no difference.
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