Studying the impact of interoperable electronic health records on workflow in ambulatory care

Many of the proposed benefits of health information systems, particularly those regarding efficiency, are assumed to be caused by changes in clinical provider and staff workflow. Assessing the extent to which electronic health records (EHRs) are having the expected effects and identifying barriers to anticipated improvements requires a detailed understanding of how such systems affect day-to-day work activities. This study utilized interviews and observations to develop prototypical workflow models of day-to-day activities in ambulatory practices, allowing activity changes due to the implementation of EHRs with varying levels of interoperability to be identified. Primary and specialty care practices from a multi-county region were sampled. Results showed that EHRs did not consistently improve efficiency, but variously reduced, added, or simply changed work tasks. The impact depended on the work process, level of interoperability, and type of provider involved, as well as aspects of the user interface design. Additionally, implementing EHR systems did not eliminate the use of paper from work processes. Implications for successful implementation and design of EHR systems are provided.Relevance to industryEffectively designing and implementing health IT systems in clinical settings requires an understanding of how the IT system will impact, and be integrated with, existing work activities, and how these impacts may depend on the level of interoperability achieved by the IT system.     

Boundary-Object Trimming: On the Invisibility of Medical Secretaries’ Care of Records in Healthcare Infrastructures

As health care IT gradually develops from being stand-alone systems towards integrated infrastructures, the work of various groups, occupations and units is likely to become more tightly integrated and dependent upon each other. Hitherto, the focus within health care has been upon the two most prominent professions, physicians and nurses, but most likely other non-clinical occupations will become relevant for the design and implementation of health care IT. In this paper, we describe the cooperative work of medical secretaries at two hospital departments, based on a study evaluating a comprehensive electronic health record (EHR) shortly after implementation. The subset of data on medical secretaries includes observation (11 hours), interviews (three individual and one group) and survey data (31 of 250 respondents were medical secretaries). We depict medical secretaries’ core task as to take care of patient records by ensuring that information is complete, up to date, and correctly coded, while they also carry out information gatekeeping and articulation work. The importance of these tasks to the departments’ work arrangements was highlighted by the EHR implementation, which also coupled the work of medical secretaries more tightly to that of other staff, and led to task drift among professions. Medical secretaries have been relatively invisible to health informatics and CSCW, and we propose the term ‘boundary-object trimming’ to foreground and conceptualize one core characteristic of their work: maintenance and optimization of the EHR as a boundary object. Finally, we reflect upon the hitherto relative invisibility of medical secretaries which may be related to issues of gender and power.     

When workarounds aggravate misfits in the use of electronic health record systems

This paper contributes to the IS misfits and workarounds literature by demonstrating how “work system–technology” misfits and workarounds can be mutually related. In the context of electronic health record (EHR) systems, this study examines when misfits experienced between an EHR system and health professionals' work practices lead to workarounds with negative consequences in terms of aggravating misfits. Our qualitative study was conducted in two tertiary hospitals in The Netherlands that had implemented an off-the-shelf EHR system. We analysed the “misfit experience → response → consequence” sequences that emerged from interviews complemented with observations and documents. Experienced misfits between the EHR and other work system components induced highly varied responses, among which workarounds. While workarounds can be beneficial, we found occasions where workarounds resulted in aggravated misfits. We conceptualise three underlying misfit-aggravating EHR-use patterns emerging from (1) a non-routine practice's perceived exceptionality, (2) collective separatism in incompatible routine practices, and (3) individual deviancy in routine work practices. These patterns differ in terms of the work practices' routineness, professionals' misfit experiences, and in how this combination provokes an individual or collective workaround that is non-compliant with both the designed technology use and the organisational intent. To understand how these patterns emerge, we discuss the interplay among work practice routineness, misfit characteristics, and non-compliant workaround behaviours.     

Reengineering the Hubble space telescope control center system

The Hubble Space Telescope was funded in the late 1970s, when mainframes still ruled the world. By the time the Hubble was launched in 1990, desktop computers were ubiquitous, powerful, and about to be hyperlinked through the Internet. Hubble's operations control center at NASA's Goddard Space Flight Center reflects these profound changes in computing technology. It has dozens of computing platforms and a control system that evolved over the course of 15 years of project development and subsequent operations. Efforts to reengineer these operational systems are now under way in a project called Vision 2000. The engineers at Goddard are implementing a three-tiered system architecture to integrate the heterogeneous computing environments that have evolved over the years. The new system uses a Web-based graphical user interface, written in Java, to enable greater access to engineering data than has ever before been possible. This GUI represents a Java implementation that is both large-scale (1.5 million lines of code) and mission-critical     

Perceived influences on implementing data warehousing

This study surveyed data warehousing implementation project participants to determine what aspects they perceived should contribute to the implementation process. The respondents included: functional managers/staff, IS managers/staff, and consultants. The study identified eight significant factors that participants perceived should impact data warehouse implementation.     

Understanding process change management in electronic health record implementations

Electronic health record (EHR) implementations involve changes to core organizational processes, and management of these changes is critical to the success of such implementation efforts. This research describes how process change issues relate to implementation of large IT projects in healthcare settings. Specifically, we draw on extant literature and conduct directed content analysis on project reports by past HIMSS Davies Award recipients to present process change related best practices occurring in EHR implementations. The results from this study can influence implementation strategies for future health information technology implementation efforts in the healthcare sector.     

Workplace user frustration with computers: an exploratory investigation of the causes and severity

When hard-to-use computers cause users to become frustrated, it can affect workplace productivity, user mood and interactions with other co-workers. Previous research has examined the frustration that students and their families face in using computers. To learn more about the causes and measure the severity of user frustration with computers in the workplace, we collected modified time diaries from 50 workplace users, who spent an average of 5.1 hours on the computer. In this exploratory research, users reported wasting on average, 42 - 43% of their time on the computer due to frustrating experiences. The largest number of frustrating experiences occurred while using word processors, email and web browsers. The causes of the frustrating experiences, the time lost due to the frustrating experiences, and the effects of the frustrating experiences on the mood of the users are discussed in this paper. Implications for designers, managers, users, information technology staff and policymakers are discussed.     

Workplace user frustration with computers: an exploratory investigation of the causes and severity

When hard-to-use computers cause users to become frustrated, it can affect workplace productivity, user mood and interactions with other co-workers. Previous research has examined the frustration that students and their families face in using computers. To learn more about the causes and measure the severity of user frustration with computers in the workplace, we collected modified time diaries from 50 workplace users, who spent an average of 5.1 hours on the computer. In this exploratory research, users reported wasting on average, 42 – 43% of their time on the computer due to frustrating experiences. The largest number of frustrating experiences occurred while using word processors, email and web browsers. The causes of the frustrating experiences, the time lost due to the frustrating experiences, and the effects of the frustrating experiences on the mood of the users are discussed in this paper. Implications for designers, managers, users, information technology staff and policymakers are discussed.     

Evaluation of a participatory ergonomic intervention process in kitchen work

We evaluated a participatory ergonomic intervention process applied in 59 municipal kitchens. In groups of three to five kitchens, the workers participated in eight workshops, and generated and evaluated solutions to optimize musculoskeletal load in their work. An ergonomist initiated and supported the process. By the end, 402 changes were implemented. Evaluative data were collected using research diaries, questionnaires, and focus group interviews. The intervention model proved feasible and the participatory approach was mostly experienced as motivating. The workers’ knowledge and awareness of ergonomics increased, which improved their ability to tackle ergonomic problems by themselves. The changes in ergonomics were perceived to decrease physical load and improve musculoskeletal health. As hindering factors for implementation, lack of time and motivation, and insufficient financial resources were mentioned. In addition, the workers expressed a wish for more support from the management, technical staff, and ergonomists.     

Work routines as an object of resistance during information systems implementations: theoretical foundation and empirical evidence

When implementing new information systems, organizations often face resistance behavior from employees who avoid or underutilize the system. We analyze the extent to which such user resistance behavior is explained by users’ perceptions of the technology compared with their perceptions of work routines. We developed a research model based on work system theory and evaluated it using a study (N=106) of a human resources information system implementation in one organization. The results show that work routines are an object of resistance during IS implementations. We identify perceived usefulness and perceived ease of executing work routines as perceptions of work routines during an IS implementation that have a strong influence on user resistance behavior. In addition, our results show that the perceived ease of executing the work routines mediates the impact of perceived ease of use on user resistance behavior. In practice, our findings imply that interventions during IT implementations should focus on both the new technology and changing work routines.     

User satisfaction and system success: an empirical exploration of user involvement in software development

For over four decades user involvement has been considered intuitively to lead to user satisfaction, which plays a pivotal role in successful outcome of a software project. The objective of this paper is to explore the notion of user satisfaction within the context of the user involvement and system success relationship. We have conducted a longitudinal case study of a software development project and collected qualitative data by means of interviews, observations and document analysis over a period of 3 years. The analysis of our case study data revealed that user satisfaction significantly contributes to the system success even when schedule and budget goals are not met. The case study data analysis also presented additional factors that contribute to the evolution of user satisfaction throughout the project. Users’ satisfaction with their involvement and the resulting system are mutually constituted while the level of user satisfaction evolves throughout the stages of software development process. Effective management strategies and user representation are essential elements of maintaining an acceptable level of user satisfaction throughout software development process.     

Mobile computers in a community NHS trust: Is this a relevant context and environment for their use?

This paper describes a case study in which mobile computers were used by a UK National Health Service (NHS) Trust. The intention was to give clinicians access to up-to-date patient data, enabling them to be more clinically effective in their jobs. Since the majority of their work was performed in the community, it was perceived that the use of hand-held computers would give the flexibility needed to allow this clinical effectiveness to occur. This paper will attempt to demonstrate what happened in reality and point to various factors that had not been considered prior to the introduction of the system. Had these factors been considered, a different system would have been designed with a better fit between the organisation, the needs of the user and their work environment.     

The relationship between usage intention and adoption of electronic health records at primary care clinics

Objective

Despite of emerging evidence that electronic health records (EHRs) can improve the clinical quality, enhances patient safety and efficiency. Most physicians in primary health care clinics in the Taiwan do not currently adopt EHR at their clinic practices. We aim to measure the relationship between usage intention and adoption behavior.

Study design and methods

We used structured questionnaires distributed both EHRs adopter and non-adopter group to the primary health care physicians which participated in the DOH project to establish the information exchange environment across Taiwan. The response rate of adopter and non-adopter is 54.7% and 55.0% respectively.

Measurements

EHRs adoption behavior.

Results

The EHRs adopter group has higher intention than non-adopter (p = 0.003). From the result of logistic regression analyses, we found the key factors affecting physicians’ adoption pattern were intention to use (OR: 2.85; 95% CI: 2.30–3.54). In addition, higher perceived usefulness (OR: 1.29; 95% CI: 1.06–1.56) and perceived ease to use (OR: 1.48; 95% CI: 1.22–1.79) increase adoption of EHR found.

Conclusion

The intention to use EHR, perceived usefulness and ease to use of primary care physicians were found as key factors influencing EHRs adoption. Thus, we suggest that government should promote the potential benefits of EHR and enhance physicians’ willingness to adopt the EHRs at their clinic practices.     

Computer-based data entry for nurses in the ICU

Efforts are being made to improve the efficiency and quality of care in intensive care units (ICUs) at Latter Day Saints Hospital. The ICUs have been computerized, and the collection, storage, and presentation of patients' data have been improved. Nurses use computers for entering clinical data and plans for nursing care, and the effects of these changes on the work patterns of nurses in the ICU have been evaluated. Contrary to our expectation, our studies showed a decrease in the proportion of time that nurses spent in direct patient care (from 49.1% to 43.2%) and an increase in the proportion they spent entering clinical data (from 18.2% to 24.2%) after computerization. These changes, however, were attributed to a decrease in the severity of patients' illnesses, rather than the availability of the computer. There was no measurable difference in the proportion of time spent at other nursing activities.     

Middleware for mobile medical data management with minimal latency

A promise of mHealth is its capacity to facilitate the consumption of Electronic Health Record (EHR) data using mobile devices, which is central to promoting remote healthcare delivery. Our ongoing project, called SOPHRA, in collaboration with the City Hospital in Saskatoon, Canada, focuses on supporting care providers (e.g., physicians) in the collection/recording of medical data from patients remotely. A major challenge that needs to be addressed is the potential loss of communication between the mobile-clients and the health information system (HIS) during the transfer of the electronic health record (EHR). Overcoming this challenge will foster soft-real time medical data exchanges. However, the issue of communication loss can be as a result of the over-reliance on wireless networks such as Wi-Fi, which can sometimes be unstable. Thus, the goal of this work is to propose a mobile health (mHealth) architectural environment that can exploit the limited available bandwidth during the mobile medical data transfer. A middleware is proposed with the capability of managing different states of the medical data as the physicians updates the EHR. The work details the employment of the Bernoulli model as a means of determining and controlling different updates of the mHealth data for effective propagation.     

Development of design principles for automated systems in transport control

This article reports the results of a qualitative study investigating attitudes towards and opinions of an advanced automation system currently used in UK rail signalling. In-depth interviews were held with 10 users, key issues associated with automation were identified and the automation's impact on the signalling task investigated. The interview data highlighted the importance of the signallers' understanding of the automation and their (in)ability to predict its outputs. The interviews also covered the methods used by signallers to interact with and control the automation, and the perceived effects on their workload. The results indicate that despite a generally low level of understanding and ability to predict the actions of the automation system, signallers have developed largely successful coping mechanisms that enable them to use the technology effectively. These findings, along with parallel work identifying desirable attributes of automation from the literature in the area, were used to develop 12 principles of automation which can be used to help design new systems which better facilitate cooperative working. PRACTITIONER SUMMARY: The work reported in this article was completed with the active involvement of operational rail staff who regularly use automated systems in rail signalling. The outcomes are currently being used to inform decisions on the extent and type of automation and user interfaces in future generations of rail control systems.     

A GIS-based borehole data management and 3D visualization system

The use of subsurface data for problem solving is limited in part by the freedom the user has in their choice of data structures. If a user is allowed to work with the data in a familiar way, they can spend more time performing analysis tasks and less time restructuring data, thus increasing productivity and reducing the risks associated with a series of data modification cycles. Borehole information system (BoreIS) is based upon this principle. Design was guided by interviews with geologists who were targeted as potential users of the software, and BoreIS was developed as an extension to ESRI's ArcScene three-dimensional (3D) GIS environment. BoreIS uses borehole or well data supplied by the user to develop a 3D GIS representation which can be queried, visualized, and analysed. By asking relevant questions about data stored in Excel spreadsheets, BoreIS can automate many high-level GIS functions so that an inexperienced GIS user can still use the system. By matching table elements to spatially and geologically significant terms through the interactive setup, users can work with the data more closely matched to the geological problem domain. This allows the novice user to use powerful GIS functions to discover spatial patterns in their data. BoreIS’ interactive manipulation of terms in complex queries, simple addition of contoured surfaces, and masking by lithology or formation helps geologists find spatial patterns in their data, beyond the limits of data tables and flat maps.     

The clinic-level perspective on mHealth implementation: a South African case study

ABSTRACT

This exploratory investigation presents a case study of the deployment of an mHealth service in established public clinics, and assesses the findings using Activity Theory. We contribute to the limited empirical research on mHealth implementation in established public facilities, and build on work on the use of Activity Theory to frame investigations of ICT4D interventions.

The study investigates the perspective of clinic staff responsible for registering women for a free maternal health messaging service. Open-ended interviews and observation sessions were used to reveal staff experiences of the implementation, and their work practices. Activity Theory analysis was adopted to help interpret the data, and identify likely dynamics leading to these specific practices.

Some themes that emerged were the hierarchical nature of the medical profession and implications for task shifting, the influence of technical design choices on use patterns and issues arising from the developing-country context.     

The process of deriving requirements for a hospital information system

This paper describes the process through which a small regional oncology hospital derived information and implementation requirements for an organization-wide information system. In part, this was in response to the recent changes in the UK National Health Service. The project was conducted in the action research tradition, combining both practical and theoretical goals, and took a stakeholder perspective. A range of methods were used to explore the issues of information and organizational needs, including questionnaires,interviews, discussion groups and 'tracer' studies. As a result of the intervention, a framework of information needs and an implementation strategy were drawn up as a plan for the hospital's continuing work in this area.