Date Published: February 25, 2019
Publisher: Public Library of Science
Author(s): Shiri Assis-Hassid, Barbara J. Grosz, Eyal Zimlichman, Ronen Rozenblum, David W. Bates, M. Barton Laws.
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.
Assess the extent to which EHRs support care team workflow during hospital morning rounds.
We applied a mixed-method approach including observations of care teams during morning rounds, semi-structured interviews and an electronic survey of hospital inpatient clinicians. Structured field notes taken during observations were used to identify workflow patterns for analysis. We applied a grounded theory approach to extract emerging themes from interview transcripts and used SPSS Statistics 24 to analyze survey responses.
Medical units at a major teaching hospital in New England.
Data triangulation across the three analyses yielded four main findings: (1) a high degree of variance in the ways care teams use EHRs during morning rounds. (2) Pervasive use of workarounds at critical points of care (3) EHRs are not used for information sharing and frequently impede intra-care team communication. (4) 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. 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.
EHRs are intended to improve various aspects of care, including patient safety, clinical decision-making and information exchange [1–3]. They may also represent a cost-effective tool for improving quality of care . Many challenges remain to effective EHR use, however, including prolonged documentation time, interference with communication, usability difficulties, lack of cognitive support, failure to support the clinical workflow and low user satisfaction [5–9]. Nonetheless, financial incentives of meaningful use criteria and the Medicare incentive program  have led to high EHR adoption rates in the U.S., with 96% of hospitals having certified EHR technology . Although these rates represent a major milestone, there is little evidence that EHRs are improving the quality of inpatient care [11,12]. 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 [15,16].
Participant characteristics are summarized in Table 1. We observed 12 care teams for a total of 50 hours and interviewed 13 clinicians including: 4 attending clinicians, 3 residents, 1 intern and 5 Physician Assistants (PAs). Our survey yielded a 30% response rate of 91 respondents: 32 attending clinicians, 26 residents, 20 interns and 13 PAs. We analyzed results of each method, and then compared the three analyses to identify recurring themes. This analysis yielded the following themes: (1) variance in EHR use patterns during morning rounds; (2) use of workarounds in care team workflow; (3) use of EHRs for information sharing and its impact on intra-care team communication; and (4) challenges presented by EHR design and usability. In the following sections we describe each theme and provide supporting findings from the observations, interviews and survey.
The objective of this study was to provide a comprehensive view of the different ways EHRs are integrated into care team workflows. We found a high variance in EHR use patterns during morning rounds and extensive use of workarounds. We also found that information from the EHR is seldom shared among care team clinicians while in the patient’s room. These finding may be at least partly explained by existing challenges in EHR design and usability. Negative effects of EHR-based technologies on clinical practice, organizational culture, medical education and patient-clinician communication have been well documented in the literature [23–26]. They include new types of errors, modification of the clinical workflow and changes in clinicians’ cognitive behaviors [2,27–32].
This study has several limitations. First, it involves a single site. Different workflows and use patterns may be observed in other settings. Second, as is typical in qualitative research, the sample size was not large. We attempted to address this limitation by conducting a mixed-methods approach including observations and semi-structured interviews as well as quantitative analysis of a user preference survey.
We evaluated an inpatient EHR, and found lack of standardized workflows, workarounds, team communication challenges, and system usability issues. Although EHRs can improve healthcare quality and have done so in many ways, our findings show that there are many challenges in the current inpatient environment that need to be addressed if EHRs are to reach their full potential.