Summary
Background: Effective communication is essential to safe and efficient patient care. Additionally,
many health information technology (HIT) developments, innovations, and standards
aim to implement processes to improve data quality and integrity of electronic health
records (EHR) for the purpose of clinical information exchange and communication.
Objective: We aimed to understand the current patterns and perceptions of communication of common
goals in the ICU using the distributed cognition and clinical communication space
theoretical frameworks.
Methods: We conducted a focus group and 5 interviews with ICU clinicians and observed 59.5
hours of interdisciplinary ICU morning rounds.
Results: Clinicians used an EHR system, which included electronic documentation and computerized
provider order entry (CPOE), and paper artifacts for documentation; yet, preferred
the verbal communication space as a method of information exchange because they perceived
that the documentation was often not updated or efficient for information retrieval.
These perceptions that the EHR is a “shift behind” may lead to a further reliance
on verbal information exchange, which is a valuable clinical communication activity,
yet, is subject to information loss.
Conclusions: Electronic documentation tools that, in real time, capture information that is currently
verbally communicated may increase the effectiveness of communication.
Keywords
ICU - communication - interdisciplinary - electronic health record
