Study to track practices' EHR workflow

Research commissioned by the Agency for Healthcare Research and Quality (AHRQ) will examine six small- to medium-sized practices that are moving to a patient-centered medical home (PCMH) model to analyze the relationship between health IT and workflow redesign.

Through its contractor, the Billings Clinic (Billings, Mont.), AHRQ will interview focus groups with clinical, non-clinical, and management staff about their experiences with electronic health records (EHRs) and other health IT, explore the influence of behavioral and organizational factors that may reduce or intensify the impact on workflow, and the effects of disruptive events.

In redesigning an office practice to the PCMH model, health IT systems are supposed to enable a seamless and organized flow of information among providers. The EHR is critical so a team of clinicians can provide continuous and coordinated care throughout a patient's lifetime.

“Unfortunately, health IT systems can fail to generate anticipated results and even carry unintended consequences which undermine usability and usefulness,” according to an announcement  published in the Jan. 28 Federal Register.

“Directly or indirectly, health IT may create more work, new work, excessive system demands or inefficient workflow [the sequence of clinical tasks],” the notice added.

For example, electronic reminders and alerts may be timed poorly. Software may require excessive switching between screens, leading to cognitive distractions for end users. Providers may spend more time on health IT system-related tasks than on direct patient care.

Research indicates that the practice environment is full of unpredictable -- yet frequently occurring -- events that require actions, such as interruptions demanding a provider's immediate attention, or disruptions in the normal functioning of the health IT system that divert healthcare staff from the usual course of workflow.

“The inability of health IT to properly accommodate these events could cause compromises to clinical work,” AHRQ said.

AHRQ will study, through the following activities, how EHR implementation alters clinical work processes and workflow:

1. Map the physician practices to detect changes made to the physical layout as a result of implementing the PCMH model and health IT.

2. Observe staff. Physicians, nurse practitioners, physician assistants, nurses, medical assistants, pharmacists, case managers and non-clinical office personnel will be observed to outline overall characteristics of clinical workflow before, during and after health IT implementation. Particular attention will be paid to interruptions and exceptions.

3. Produce before-and-after time and motion studies to quantify staff time observed spent on different clinical activities and the sequence of executing tasks.

4. Extract clinical data in logs and audit trails that have been time-stamped from the EHR to reconstruct clinical workflow related to the health IT system. This information validates and supplements the data recorded by human observers.

5. Conduct semi-structured interviews of end users, including staff, non-clinical personnel and management post-health IT implementation to obtain attitudes and perceptions regarding how health IT has changed their workflow, particularly behavioral and organizational factors.

6. Form focus groups made up of the clinical staff, non-clinical personnel and management team to ensure that the research findings, as well as the interpretation of the findings, accurately reflect their experiences using health IT.