Physician Workflow in Two Distinctive Emergency Departments: An Observational StudyFunding This research is supported by a grant (no. R01HS022670) from the Agency for Healthcare Research and Quality (AHRQ). The content is the sole responsibility of the authors and does not necessarily represent the official views of AHRQ.
Objectives We characterize physician workflow in two distinctive emergency departments (ED). Physician practices mediated by electronic health records (EHR) are explored within the context of organizational complexity for the delivery of care.
Methods Two urban clinical sites, including an academic teaching ED, were selected. Fourteen physicians were recruited. Overall, 62 hours of direct clinical observations were conducted characterizing clinical activities (EHR use, team communication, and patient care). Data were analyzed using qualitative open-coding techniques and descriptive statistics. Timeline belts were used to represent temporal events.
Results At site 1, physicians, engaged in more team communication, followed by direct patient care. Although physicians spent 61% of their clinical time at workstations, only 25% was spent on the EHR, primarily for clinical documentation and review. Site 2 physicians engaged primarily in direct patient care spending 52% of their time at a workstation, and 31% dedicated to EHRs, focused on chart review. At site 1, physicians showed nonlinear complex workflow patterns with a greater frequency of multitasking and interruptions, resulting in workflow fragmentation. In comparison, at site 2, a less complex environment with a unique patient assignment system, resulting in a more linear workflow pattern.
Conclusion The nature of the clinical practice and EHR-mediated workflow reflects the ED work practices. Physicians in more complex organizations may be less efficient because of the fragmented workflow. However, these effects can be mitigated by effort distribution through team communication, which affords inherent safety checks.
Keywordsclinical workflow - emergency medicine - electronic health records - complexity - patient safety
Protection of Human and Animal Subjects
The institutional review boards of New York Academy of Medicine, Icahn School of Medicine at Mount Sinai, and Mayo Clinic approved this study. Written consents were obtained from all participants.
Received: 23 August 2020
Accepted: 06 December 2020
03 March 2021 (online)
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- 1 Kannampallil TG, Schauer GF, Cohen T, Patel VL. Considering complexity in healthcare systems. J Biomed Inform 2011; 44 (06) 943-947
- 2 Leape LL, Berwick DM. Five years after to err is human: what have we learned?. JAMA 2005; 293 (19) 2384-2390
- 3 Laxmisan A, Hakimzada F, Sayan OR, Green RA, Zhang J, Patel VL. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform 2007; 76 (11-12): 801-811
- 4 Phelan S. What is complexity science, really?. Emergence 2001;3(01):
- 5 Smith M, Feied C. The Emergency Department as a Complex System. New England Complex Systems Institute; . Published online 1999. Accessed July 7, 2020 at: https://necsi.edu/the-emergency-department-as-a-complex-system
- 6 Chisholm CD, Weaver CS, Whenmouth L, Giles B. A task analysis of emergency physician activities in academic and community settings. Ann Emerg Med 2011; 58 (02) 117-122
- 7 Hose B-Z, Hoonakker PLT, Wooldridge AR. et al. Physician perceptions of the electronic problem list in pediatric trauma care. Appl Clin Inform 2019; 10 (01) 113-122
- 8 Washington V, DeSalvo K, Mostashari F, Blumenthal D. The HITECH era and the path forward. N Engl J Med 2017; 377 (10) 904-906
- 9 Denton CA, Soni HC, Kannampallil TG. et al. Emergency physicians' perceived influence of EHR use on clinical workflow and performance metrics. Appl Clin Inform 2018; 9 (03) 725-733
- 10 Mamykina L, Vawdrey DK, Stetson PD, Zheng K, Hripcsak G. Clinical documentation: composition or synthesis?. J Am Med Inform Assoc 2012; 19 (06) 1025-1031
- 11 Hill Jr RG, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med 2013; 31 (11) 1591-1594
- 12 Neri PM, Redden L, Poole S. et al. Emergency medicine resident physicians' perceptions of electronic documentation and workflow: a mixed methods study. Appl Clin Inform 2015; 6 (01) 27-41
- 13 Handel DA, Hackman JL. Implementing electronic health records in the emergency department. J Emerg Med 2010; 38 (02) 257-263
- 14 Zheng K, Haftel HM, Hirschl RB, O'Reilly M, Hanauer DA. Quantifying the impact of health IT implementations on clinical workflow: a new methodological perspective. J Am Med Inform Assoc 2010; 17 (04) 454-461
- 15 Patel VL, Cohen T. New perspectives on error in critical care. Curr Opin Crit Care 2008; 14 (04) 456-459
- 16 Patel VL, Kannampallil TG, Shortliffe EH. Role of cognition in generating and mitigating clinical errors. BMJ Qual Saf 2015; 24 (07) 468-474
- 17 Lyell D, Magrabi F, Coiera E. The effect of cognitive load and task complexity on automation bias in electronic prescribing. Hum Factors 2018; 60 (07) 1008-1021
- 18 Harris M, Wood J. Resuscitate ED metrics with split-flow design. Healthc Financ Manage 2012; 66 (12) 76-79
- 19 Traub SJ, Bartley AC, Smith VD, Didehban R, Lipinski CA, Saghafian S. Physician in triage versus rotational patient assignment. J Emerg Med 2016; 50 (05) 784-790
- 20 Zheng L, Kaufman DR, Duncan BJ. et al. A task-analytic framework comparing preoperative electronic health record-mediated nursing workflow in different settings. Comput Inform Nurs 2020; 38 (06) 294-302
- 21 Abraham J, Kannampallil T, Brenner C. et al. Characterizing the structure and content of nurse handoffs: a sequential conversational analysis approach. J Biomed Inform 2016; 59: 76-88
- 22 Ammenwerth E, Spötl H-P. The time needed for clinical documentation versus direct patient care. A work-sampling analysis of physicians' activities. Methods Inf Med 2009; 48 (01) 84-91
- 23 Larcos G, Prgomet M, Georgiou A, Westbrook J. A work observation study of nuclear medicine technologists: interruptions, resilience and implications for patient safety. BMJ Qual Saf 2017; 26 (06) 466-474
- 24 Microsoft Excel 2016 Spreadsheet Software, Excel Free Trial. Accessed September 21, 2017 at: https://products.office.com/en-us/excel
- 25 Flowchart Maker & Online Diagram Software. Lucidchart. Published May 6, 2015. Accessed June 30, 2017 at: https://www.lucidchart.com
- 26 Monsell S. Task switching. Trends Cogn Sci 2003; 7 (03) 134-140 (Regul Ed)
- 27 Li SYW, Magrabi F, Coiera E. A systematic review of the psychological literature on interruption and its patient safety implications. J Am Med Inform Assoc 2012; 19 (01) 6-12
- 28 Dodhia RM, Dismukes RK. Interruptions create prospective memory tasks. Appl Cogn Psychol 2009; 23 (01) 73-89
- 29 Cohen T, Blatter B, Almeida C, Shortliffe E, Patel V. A cognitive blueprint of collaboration in context: distributed cognition in the psychiatric emergency department. Artif Intell Med 2006; 37 (02) 73-83
- 30 Rubinstein JS, Meyer DE, Evans JE. Executive control of cognitive processes in task switching. J Exp Psychol Hum Percept Perform 2001; 27 (04) 763-797
- 31 Westbrook JI, Coiera E, Dunsmuir WTM. et al. The impact of interruptions on clinical task completion. Qual Saf Health Care 2010; 19 (04) 284-289
- 32 Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010; 170 (08) 683-690
- 33 Brixey JJ, Tang Z, Robinson DJ. et al. Interruptions in a level one trauma center: a case study. Int J Med Inform 2008; 77 (04) 235-241
- 34 Patel VL, Shine AL, Almoosa KF. Error Recovery in the Wilderness of ICU. In: Patel VL, Kaufman DR, Cohen T. eds. Cognitive Informatics in Health and Biomedicine: Case Studies on Critical Care, Complexity and Errors. Health Informatics. Springer; 2014: 91-111
- 35 Patel VL, Cohen T, Batwara S, Almoosa KF. Teamwork and Error Management in Critical Care. In: Patel VL, Kaufman DR, Cohen T. eds. Cognitive Informatics in Health and Biomedicine: Case Studies on Critical Care, Complexity and Errors. Health Informatics. Springer; 2014: 59-90