Workarounds and Test Results Follow-up in Electronic Health Record-Based Primary CareDr. Singh is supported by the VA Health Services Research and Development Service (CRE 12–033; Presidential Early Career Award for Scientists and Engineers USA 14–274), the VA National Center for Patient Safety and the Agency for Health Care Research and Quality (R01HS022087). This work is supported in part by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413).
22 October 2015
accepted: 05 April 2016
16 December 2017 (online)
Electronic health records (EHRs) have potential to facilitate reliable communication and follow-up of test results. However, limitations in EHR functionality remain, leading practitioners to use workarounds while managing test results. Workarounds can lead to patient safety concerns and signify indications as to how to build better EHR systems that meet provider needs.
To understand why primary care practitioners (PCPs) use workarounds to manage test results by analyzing data from a previously conducted national cross-sectional survey on test result management.
We conducted a secondary data analysis of quantitative and qualitative data from a national survey of PCPs practicing in the Department of Veterans Affairs (VA) and explored the use of workarounds in test results management. We used multivariate logistic regression analysis to examine the association between key sociotechnical factors that could affect test results follow-up (e.g., both technology-related and those unrelated to technology, such as organizational support for patient notification) and workaround use. We conducted a qualitative content analysis of free text survey data to examine reasons for use of workarounds.
Of 2554 survey respondents, 1104 (43%) reported using workarounds related to test results management. Of these 1028 (93%) described the type of workaround they were using; 719 (70%) reported paper-based methods, while 230 (22%) used a combination of paper- and computer-based workarounds. Primary care practitioners who self-reported limited administrative support to help them notify patients of test results or described an instance where they personally (or a colleague) missed results, were more likely to use workarounds (p=0.02 and p=0.001, respectively). Qualitative analysis identified three main reasons for workaround use: 1) as a memory aid, 2) for improved efficiency and 3) for facilitating internal and external care coordination.
Workarounds to manage EHR-based test results are common, and their use results from unmet provider information management needs. Future EHRs and the respective work systems around them need to evolve to meet these needs.
- 1 Singh H, Naik AD, Rao R, Petersen LA. Reducing diagnostic errors through effective communication: harnessing the power of information technology. J Gen Intern Med 2008; 23 (04) 489-494 doi: 10.1007/s11606–007–0393-z. PubMed PMID: 18373151.
- 2 Hysong SJ, Sawhney MK, Wilson L, Sittig DF, Esquivel A, Singh S, Singh H. Understanding the management of electronic test result notifications in the outpatient setting. BMC Med Inform Decis Mak 2011; 11: 22 doi: 10.1186/1472–6947–11–22. PubMed PMID: 21486478.
- 3 Saleem JJ, Russ AL, Justice CF, Hagg H, Ebright PR, Woodbridge PA, Doebbeling BN. Exploring the persistence of paper with the electronic health record. Int J Med Inform 2009; 78 (09) 618-628 doi: 10.1016/j.ijmedinf.2009.04.001. Epub 2009 May 21. PubMed PMID:19464231.
- 4 Van Der Sijs H, Rootjes I, Aarts J. The shift in workarounds upon implementation of computerized physician order entry. Stud Health Technol Inform 2011; 169: 290-4 PubMed PMID:21893759.
- 5 Gasser L. The integration of computing and routine work. ACM Transactions on Information System(TOIS) 1986; 04 (03) 205-225 doi10.1145/214427.214429.
- 6 Friedman A, Crosson JC, Howard J, Clark EC, Pellerano M, Karsh BT, Crabtree B, Jaen CR, Cohen DJ. A typology of electronic health record workarounds in small-to-medium size primary care practices. J Am Med Inform Assoc 2014; 21 (e1): e78-e83 doi: 10.1136/amiajnl-2013–001686. Epub 2013 Jul 31.PubMed PMID: 23904322.
- 7 Casalino LP, Dunham D, Chin MH, Bielang R, Kistner EO, Karrison TG, Ong MK, Sarkar U, McLaughlin MA, Meltzer DO. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med 2009; 169 (12) 1123-1129 doi: 10.1001/archinternmed.2009.130. PubMed PMID:19546413.
- 8 Flanagan ME, Saleem JJ, Millitello LG, Russ AL, Doebbeling BN. Paper- and computer-based workarounds to electronic health record use at three benchmark institutions. J Am Med Inform Assoc 2013; 20 (e1): e59-e66 doi: 10.1136/amiajnl-2012–000982. Epub 2013 Mar 14. PMID: 23492593.
- 9 Singh H, Thomas EJ, Mani S, Sittig D, Arora H, Espadas D, Khan MM, Petersen LA. Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?. Arch Intern Med 2009; 169 (17) 1578-1586 doi: 10.1001/archinternmed 2009.263. PubMed PMID:19786677.
- 10 Callen JL, Westbrook JI, Georqiou A, Li J. Failure to follow-up test results for ambulatory patients: a systematic review. J Gen Intern Med 2012; (10) 1334-1348 Epub 2011 Dec 20. PubMed PMID:22183961.
- 11 Elder NC, McEwen TR, Flach JM, Gallimore JJ. Management of Test Results in Family Medicine Offices. Ann Fam Med 2009; 07 (04) 343-351 doi: 10.1370/afm.961. PubMed PMID:19597172.
- 12 Singh H, Thomas EJ, Sittig DF, Wilson L, Espadas D, Khan MM, Petersen LA. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?. Am J Med 2010; 123: 238-244 doi: 10.1016/j.amjmed.2009.07.027. PubMed PMID:20193832.
- 13 Debono DS, Greenfield D, Travaglia JF, Long JC, Black D, Johnson J, Braithwaite J. Nurses’ workarounds in acute healthcare settings: a scoping review. BMC Health Serv Res 2013; 13: 175 doi: 10.1186/1472–6963–13–175. PubMed PMID:23663305.
- 14 Collins SA, Fred M, Wilcox L, Vawdrey DK. Workarounds Used by Nurses to Overcome Design Constraints of Electronic Health Records. NI 2012: Proceedings of the 11th International Congress on Nursing Informatics 2012; 2012: 093 eCollection 2012. PubMed PMID:24199061.
- 15 Halbesleben JR, Savage GT, Wakefield DS, Wakefield BJ. Rework and workarounds in nurse medication administration process: implications for work processes and patient safety. Health Care Manage Rev 2010; 35 (02) 124-133 doi: 10.1097/HMR. 0b013e3181d116c2. PubMed PMID:20234219. \.
- 16 Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc 2006; 13 (05) 547-556 Epub 2006 Jun 23. PubMed PMID:16799128.
- 17 Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inf Assoc 2008; 15 (04) 408-423 doi: 10.1197/jamia.M2616. Epub 2008 Apr 24. PubMed PMID:18436903.
- 18 Rack LL, Dudjak LA, Wolf GA. Study of nurse workarounds in a hospital using bar code medication administration system. J Nurs Care Qual 2012; 27 (03) 232-239 doi: 10.1097/NCQ.0b013e318240a854. PubMed PMID:22202186.
- 19 Saleem JJ, Russ AL, Neddo A, Blades PT, Doebbeling BN, Foresman BH. Paper persistence, workarounds, and communication breakdowns in computerized consultation management. Int J Med Inform 2011; 80 (07) 466-479 doi: 10.1016/j.ijmedinf.2011.03.016. Epub 2011 May 6. PubMed PMID:21530383.
- 20 Singh H, Spitzmueller C, Petersen NJ, Sawhney MK, Smith MW, Murphy DR, Espadas D, Laxmisan A, Sittig DF. Primary care practitioners’ views on test result management in EHR-enabled health systems: a national survey. J Am Med Inf Assoc 2013; 20 (04) 727-735 doi: 10.1136/amiajnl-2012–001267. Epub 2012 Dec 25. PubMed PMID:23268489.
- 21 Weber PR. Basic Content Analysis. 2nd ed. SAGE University paper series on Quantitative Applications in Social Seciences. ISBN.0–8039–3863–2. Newbury Park, CA: Sage Publications, Inc; 1990
- 22 Kim J, Mueller C. Introduction to factor analysis: Statistical Methods and Practical issues. Uslaner EM. editor. University paper series on Quantitative Applications in Social Seciences. ISBN 0–8039–1166–1. Newbury Park, CA: Sage Publications, Inc; 1978
- 23 Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs 2008; 62 (01) 107-115 doi: 10.1111/j.1365–2648.2007.04569.x PubMed PMID:18352969.
- 24 Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc 2007; 14 (04) 415-423 Epub 2007 Apr 25. PubMed PMID: 17460127.\.
- 25 Westphal J, Lancaster R, Park D. (2014). Work-arounds observed by fourth-year nursing students. Western J of Nursing Research 2013; 36 (08) 1002-1018 PubMed PMID:24284278.
- 26 Bates DW, Boyle DL, Teich JM. Impact of computerized physician order entry on physician time. Proceedings of the Annual Symposium of Computer Appllications in Medical Care 1994; 996 PubMed PMID:7950101.
- 27 Murphy DR, Reis B, Sittig DF, Singh H. Notifications received by primary care practitioners in electronic health records: a taxonomy and time analysis. Am J Med 2012; 125 (02) 209-217 doi: 10.1016/j.amjmed.2011.07.029. PubMed PMID:22269625.
- 28 Ferneley EH, Sobreperez P. Resist, comply or workaround? An examination of different facets of user engagement with information systems. Eur J Infom Sys 2006; (15) 345-356 doi: 10.1057/palgrave.ejis.3000629.
- 29 Sparnon E. Spotlight on Electronic Health Record Errors: Paper or Electronic Hybrid Workflows. Patient Saf Advis 2013; 10 (02) 55-58 Available from: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLi- brary/2013/sep;10(3)/Pages/92.aspx