The aim of this investigation was to assess helpful and challenging aspects of electronic health information with respect to clinical workflow and identify a set of characteristics that support patient care processes. We conducted 20 semi-structured interviews at a Veterans Affairs Medical Center, with a fully implemented electronic health record (EHR), and elicited positive and negative examples of how information technology (IT) affects the work of healthcare employees. Responses naturally shed light on information characteristics that aid work processes. We performed a secondary analysis on interview data and inductively identified characteristics of electronic information that support healthcare workflow. Participants provided 199 examples of how electronic information affects workflow. Seventeen characteristics emerged along with four primary domains: trustworthy and reliable; ubiquitous; effectively displayed; and adaptable to work demands. Each characteristic may be used to help evaluate health information technology pre- and post-implementation. Results provide several strategies to improve EHR design and implementation to better support healthcare workflow.
Doebbeling B.N. , Chou A.F., Tierney W.M., 2006. Priorities and strategies for the implementation of integrated informatics and communications technology to improve evidence-based practice. Journal of General Internal Medicine21 Suppl 2; S50-7.
2.
Bates D.W., Gawande A.A., 2003. Improving safety with information technology. New England Journal of Medicine348 (25); 2526-34.
3.
Saleem J.J., Patterson E.S., Militello L., Render M.L., Orshansky G., Asch S.M., 2005. Exploring barriers and facilitators to the use of computerized clinical reminders. Journal of the American Medical Informatics Association12 (4); 438-47.
4.
Safran C., 2001. Electronic medical records: a decade of experience. Journal of the American Medical Association285 (13); 1766.
5.
Weingart S.N. , Toth M., Sands D.Z., Aronson M.D., Davis R.B., Phillips R.S., 2003. Physicians’ decisions to override computerized drug alerts in primary care. Archives of Internal Medicine163 (21); 2625-31.
6.
Ko Y., Abarca J., Malone D.C., et al., 2007. Practitioners’ views on computerized drug-drug interaction alerts in the VA system. Journal of the American Medical Informatics Association14 (1); 56-64.
7.
Kaelber D.C. , Bates D.W., 2007. Health information exchange and patient safety. Journal of Biomedical Informatics40 (6Suppl); S40-5.
8.
Campbell E.M. , Sittig D.F., Ash J.S., Guappone K.P., Dykstra R.H., 2006. Types of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association13 (5); 547-56.
9.
Powsner S.M. , Wyatt J.C., Wright P., 1998. Opportunities for and challenges of computerisation. Lancet352 (9140); 1617-22.
10.
Walker J.M. , Carayon P., Leveson N., et al., 2008. EHR safety: the way forward to safe and effective systems. Journal of the American Medical Informatics Association15 (3); 272-7.
11.
Carroll J.M., Chin G., Rosson M.B., Neale D.C., 2000. Development of cooperation: five years of participatory design in the virtual school. Proceedings of the Conference on Designing Interactive Systems: Processes, Practices, Methods, and Techniques, DIS’2000, 17-19 August, New York. ACM.
12.
Nemeth C., Nunnally M., O’Connor M., Klock P.A., Cook R., 2005. Getting to the point: developing IT for the sharp end of healthcare. Journal of Biomedical Informatics38 (1); 18-25.
13.
Saleem J J. , Russ A L., Justice C F., et al., 2009. Exploring the persistence of paper with the electronic health record. International Journal of Medical Informatics78 (9); 618-28.
14.
Wears R.L., 2008. The chart is dead - long live the chart. Annals of Emergency Medicine April 30.
15.
Sellen A., Harper R., 1997. Paper as an analytic resource for the design of new technologies . Proceedings of the SIGCHI Conference on Human Factors in Computing Systems1997, 22-27 March, Atlanta.
16.
Sellen A., Harper R., 2001. The Myth of the Paperless Office. Cambridge, MA: MIT Press.
17.
Weir C.R., Nebeker J.J., Hicken B.L., Campo R., Drews F., Lebar B., 2007. A cognitive task analysis of information management strategies in a computerized provider order entry environment. Journal of the American Medical Informatics Association14 (1); 65-75.
18.
Unertl K.M., Weinger M., Johnson K., 2007. Variation in use of informatics tools among providers in a diabetes clinic. AMIA Annual Symposium Proceedings 756-60.
19.
Patterson E.S. , Cook R.I., Render M.L., 2002. Improving patient safety by identifying side effects from introducing bar coding in medication administration . Journal of the American Medical Informatics Association9 (5); 540-53.
20.
Slaughter L., Keselman A., Kushniruk A., Patel V.L., 2005. A framework for capturing the interactions between laypersons’ understanding of disease, information gathering behaviors, and actions taken during an epidemic. Journal of Biomedical Informatics38 (4); 298-313.
21.
Castel L.D. , Williams K.A., Bosworth H.B., et al., 2008. Content validity in the PROMIS social-health domain: a qualitative analysis of focus-group data. Quality of Life Research17 (5); 737-49.
22.
Miller W.L. , Crabtree B.F., 1994. Qualitative analysis: how to begin making sense. Family Practice Research Journal14 (3); 289-97.
23.
Zandieh S.O. , Yoon-Flannery K., Kuperman G.J., Langsam D.J., Hyman D., Kaushal R., 2008. Challenges to EHR implementation in electronic- versus paper-based office practices. Journal of General Internal Medicine23 (6); 755-61.
24.
Smith P.C.Araya-Guerra R., Bublitz C., et al., 2005. Missing clinical information during primary care visits. Journal of the American Medical Association293 (5); 565-71.
25.
Christensen T., Grimsmo A., 2008. Instant availability of patient records, but diminished availability of patient information: a multi-method study of GPs’ use of electronic patient records. BMC Medical Informatics Decision Making8; 12.
26.
Logan J.R., Gorman P.N., Middleton B., 2001. Measuring the quality of medical records: a method for comparing completeness and correctness of clinical encounter data. Proceedings AMIA Symposia 408-12.
27.
Buckovich S.A. , Rippen H.E., Rozen M.J., 1999. Driving toward guiding principles: a goal for privacy, confidentiality, and security of health information . Journal of the American Medical Informatics Association6 (2); 122-33.
28.
Cchit,2008. A Physician’s Guide to Certification for 08 EHRs . Chicago: Certification Commission for Healthcare Information Technology, 2008.
29.
Cchit, 2007. Ambulatory Functionality, 2007 Final Criteria. Chicago : Certification Commission for Healthcare Information Technology.
30.
Laerum H., Karlsen T.H., Faxvaag A., 2003. Effects of scanning and eliminating paper-based medical records on hospital physicians’ clinical work practice. Journal of the American Medical Informatics Association10 (6); 588-95.
31.
Harper R.H. , O’Hara K.P., Sellen A.J., Duthie D.J., 1997. Toward the paperless hospital?British Journal of Anaesthesia78 (6); 762-7.
32.
Prgomet M., Georgiou A., Westbrook J I., 2009. The impact of mobile handheld technology on hospital physicians’ work practices and patient care: a systematic review. Journal of the American Medical Informatics Association August 28 (epub ahead of print).
33.
Kilbridge P.M. , Classen D.C., 2008. The informatics opportunities at the intersection of patient safety and clinical informatics. Journal of the American Medical Informatics Association15 (4); 397-407.
34.
Karsh B.T., Holden R.J., Alper S.J., Or C.K., 2006. A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional. Quality & Safety in Health Care15 Suppl1; i59-65.
35.
Weir C.R., Nebeker J.R., 2007. Critical issues in an electronic documentation system . AMIA Annual Symposium Proceedings 786-90.
36.
Hartzband P., Groopman J., 2008. Off the record: avoiding the pitfalls of going electronic . New England Journal of Medicine358 (16); 1656-8.
37.
Drews F.A., Westenskow D.R., 2007. Human-computer interaction in health care. In Carayon P, ed., Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ: Erlbaum, pp. 423-37.
38.
Reason J., 2004. Beyond the organisational accident: the need for ‘error wisdom’ on the frontline. Quality & Safety in Health Care13 Suppl2; ii28-33.
39.
Stausberg J., Koch D., Ingenerf J., Betzler M., 2003. Comparing paper-based with electronic patient records: lessons learned during a study on diagnosis and procedure codes. Journal of the American Medical Informatics Association10 (5); 470-7.
40.
Saleem J. J, Patterson E.S., Militello L., et al., 2007. Impact of clinical reminder redesign on learnability, efficiency, usability, and workload for ambulatory clinic nurses . Journal of the American Medical Informatics Association14 (5); 632-40.
41.
Hardey M., Payne S., Coleman P., 2000. ‘Scraps’: hidden nursing information and its influence on the delivery of care. Journal of Advanced Nursing32 (1); 208-14.
42.
Varpio L., Schryer C.F., Lehoux P., Lingard L., 2006. Working off the record: physicians’ and nurses’ transformations of electronic patient record-based patient information. Academic Medicine Journal81 (10Suppl); S35-9.
43.
Horsky J., Kuperman G.J., Patel V.L., 2005. Comprehensive analysis of a medication dosing error related to CPOE. Journal of the American Medical Informatics Association12 (4); 377-82.
44.
Ash J.S. , Berg M., Coiera E., 2004. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. Journal of the American Medical Informatics Association11 (2); 104-12.
45.
Wachter R.M. , 2006. Expected and unanticipated consequences of the quality and information technology revolutions. Journal of the American Medical Association295 (23); 2780-3.
46.
Weiner J.P. , Kfuri T., Chan K., Fowles J.B., 2007. ‘e-Iatrogenesis’: the most critical unintended consequence of CPOE and other HIT. Journal of the American Medical Informatics Association14 (3); 387-8; discussion 9.
47.
Koppel R., Metlay J.P., Cohen A., et al., 2005. Role of computerized physician order entry systems in facilitating medication errors. Journal of the American Medical Association293 (10); 1197-203.
48.
Elder N.C., Hickner J., 2005. Missing clinical information: the system is down. Journal of the American Medical Association293 (5); 617-19.
49.
Carayon P., Schoofs Hundt A., Karsh B.T., et al., 2006Work system design for patient safety: the SEIPS model. Quality and Safety in Health Care15 Suppl1; i50-8.
50.
Saleem J.J. , Russ A.L., Sanderson P., Johnson T.R., Zhang J., Sittig D.F., 2009. Current challenges and opportunities for better integration of human factors research with development of clinical information systems. IMIA Yearbook of Medical Informatics4; 48-58.
51.
Tucker A.L. , Edmondson A.C., 2003. Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. California Management Review45 (2); 55-72.
52.
Kushniruk A.W. , Patel V.L., 2004. Cognitive and usability engineering methods for the evaluation of clinical information systems. Journal of Biomedical Informatics37 (1); 56-76.
53.
Fitzpatrick G. , 2004. Integrated care and the working record. Health Informatics Journal10 (4); 291-302.
54.
Kaplan B., 2001. Evaluating informatics applications: some alternative approaches. Theory, social interactionism, and call for methodological pluralism . International Journal of Medical Informatics64 (1); 39-56.
55.
Sittig D.F., Wright A., Osheroff J.A., et al., 2008. Grand challenges in clinical decision support . Journal of Biomedical Informatics41 (2); 387-92.
56.
Horwitz L.I., Meredith T., Schuur J.D., Shah N.R., Kulkarni R.G., Jenq G.Y., 2008. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Annals of Emergency Medicine June 13.
57.
Hynes D.M., Perrin R.A., Rappaport S., Stevens J.M., Demakis J.G., 2004. Informatics resources to support health care quality improvement in the veterans health administration. Journal of the American Medical Informatics Association11 (5); 344-50.
