A Qualitative analysis of Emergency Department physicians' practices and perceptions in relation to test result follow-up

Follow-up of abnormal test results for discharged Emergency Department (ED) patients is a critical safety issue. This study aimed to explore ED physicians' perceptions, practices, and suggestions for improvements of test result follow-up when using an electronic provider order entry system to order all laboratory and radiology tests and view results. Interviews were conducted with seven ED physicians and one clinical information system support person. Interviews were analyzed to elicit key concepts relating to physicians' perceptions of test result follow-up and how the process could be improved. Results described the current electronic test result follow-up system with two paper-based manual back-up systems for microbiology and radiology results. The key issues for physicians were: responsibility for test follow-up; the unique ED environment and time pressures, and the role of the family physician in test result follow-up. The key suggestion for improvement was a complete integrated electronic information system with on-line result endorsement. The study highlighted the complexity of the test result follow-up process and the importance of engaging clinicians in devising solutions for improvements.5 page(s

The use of health information technology in the follow-up of patient test results: an exploration of the experiences and views of primary care staff in the North East of England

Background Computerisation in general practices in the UK over the last 30 years has enabled paperless clinical record keeping but the process of ordering tests and receiving results electronically from hospital systems has been a relatively recent development. The Integrated Clinical Environment System (ICE) provides an electronic link between general practices and hospital-based facilities, facilitating the timely transfer of test results across healthcare boundaries. Whilst the existing literature covers the technical aspects of such systems, there is a paucity of information about how these systems function in real life and what views healthcare staff have of using them. Aims and Objectives This research sought to ascertain the experiences and views of health care staff in general practice about their use of health information technology (HIT) systems for the ordering, processing and follow-up of test results. The research described the test ordering processes and the subsequent actions taken by healthcare professionals. It provided an understanding of different staff roles in this process, including what obstacles GPs and administrative staff faced and their views on the possible subsequent impact these obstacles had on patient care. The human element in the process of requesting and dealing with test results has not been previously described in detail. Methodology The programme of work comprises, in the first section, a narrative and systematic review of the literature, initially from the UK and then, because of a paucity of data, the global setting, on using HIT to order and act on test results. This was followed by a description of the established Donabedian model for evaluating healthcare processes through the stages of structure, process and outcome, with a description of how these components applied to this research. The third section of the thesis consisted of empirical qualitative research project involving semi-structured interviews with 18 staff members from 13 general practices within the North East of England, to ascertain and explore their experiences, views and perceptions around using HIT systems for the follow-up of test results. A conceptual framework was generated by which these data were labelled and sorted. The analysis process involved identifying recurring themes and concepts. Results The reviews indicated that users found the HIT systems easy to use and felt that these systems improved their efficiency compared with the previous paper-based systems, which was confirmed in this study. A new finding, reflecting aspects of the literature, was that results’ management was also perceived to be associated with increased workload, sometimes due to receiving multiple warning alerts about abnormal findings and because of results received from tests done elsewhere. A further, new finding, was the blurring of responsibility and duties about who should review, interpret and act on certain test results received. This task was sometimes left to administrative staff, whose role was to file ‘normal’ results but often found themselves in a position of not knowing whether such results had clinical significance. This factor appeared to be related to GP workload and the delegation of tasks. Participants also felt that the numbers of tests ordered and received had increased, an issue highlighted recently in the literature. There also appeared to be an increasing level of dis-continuity in the clinical care provided in practices, related in part to the use of locum and sessional doctors. Tests ordered were not necessarily designated for follow-up by a specific doctor. These factors may also be contributing to the increasing number of tests ordered. Conclusions and Discussion This study found that whilst the new HIT systems for tests have been associated with ease of use and efficiency in the transfer and availability of results, there appears to be a number of challenges in processing and actioning these results. Applying the Donabedian model for evaluating healthcare processes through the stages of structure, process and outcome shows how the components of the differing procedures have potential drawbacks and could contribute to compromised patient care. This is largely related to the changing structures of general practice whereby continuity of care can be a problem. There appeared to be no standardised procedures for dealing with tests and a standardised approach might be a necessary way forward. This work revealed the importance of human factors in the structure and process of tests results’ management, and how clarification of responsibilities and maintenance of continuity of care are crucial elements in delivering high quality care

A qualitative study of workflow and information systems within Emergency Departments in the UK

Background: Health Information Technology (HIT) has the potential to improve the quality and efficiency of healthcare delivery and reduce costs. However, the integration of HIT into healthcare workflows has experienced a range of issues during its implementation. It can adversely impact healthcare workflows, therefore reducing efficiency and safety in healthcare delivery. As healthcare settings are characterised by its own workflow, an in-depth understanding of the workflows of where the HIT to be implemented is crucial in order to avoid complexities that can arise. As there is a lack of research investigating an overall ED workflow, both clinical and non-clinical processes and practices, this research aims to gain an in-depth understanding of emergency care workflow which includes the work processes and practices of its clinicians and non-clinicians and its information artefacts. Methodology: This research employed a fieldwork case study approach analysing the work processes and practices of clinicians and non-clinicians in the delivery of emergency care. The approach was used in order to capture the situated nature of the ED workflow. The study was conducted in two emergency care settings located in the UK. Data were collected using semi-structured interviews, non-participant observations and documents. A multiple triangulation technique: data triangulation and within-methods triangulation were employed in order to gain an in-depth understanding of the topic. The data were analysed using thematic analysis. Findings: The emergency care workflow consisted of multidisciplinary ED team members’ work processes. These work processes were comprised of collaborative clinical and non-clinical tasks and activities in delivering care treatment governed and defined by time-related activities, organisational rules, exceptions and variability. The workflow was supported by both computerised systems and non-computerised information artefacts, such as non-electronic whiteboards and paper-based records and forms, which needed to be used in conjunction with each other. Additionally, the hybrid implementation had also been utilised to support collaborative work of the clinicians and non-clinicians, hence giving the implication that HIT systems should not be designed as purely technical system focusing on single users, but also as a collaborative work system. Conclusion: An ED workflow consists of interrelated care processes, clinical and non-clinical processes. These processes are executed semi-autonomously by clinicians and non-clinicians and governed by time-related organisational constraints, variable and exception-filled, relying on hybrid information architecture. The architecture presented workflow with a number of integration issues. However, its implementation does not only support the functionalities for the delivery of emergency care processes but also the collaborative practices of the clinicians and non-clinicians

A qualitative study of workflow and information systems within Emergency Departments in the UK

Background: Health Information Technology (HIT) has the potential to improve the quality and efficiency of healthcare delivery and reduce costs. However, the integration of HIT into healthcare workflows has experienced a range of issues during its implementation. It can adversely impact healthcare workflows, therefore reducing efficiency and safety in healthcare delivery. As healthcare settings are characterised by its own workflow, an in-depth understanding of the workflows of where the HIT to be implemented is crucial in order to avoid complexities that can arise. As there is a lack of research investigating an overall ED workflow, both clinical and non-clinical processes and practices, this research aims to gain an in-depth understanding of emergency care workflow which includes the work processes and practices of its clinicians and non-clinicians and its information artefacts. Methodology: This research employed a fieldwork case study approach analysing the work processes and practices of clinicians and non-clinicians in the delivery of emergency care. The approach was used in order to capture the situated nature of the ED workflow. The study was conducted in two emergency care settings located in the UK. Data were collected using semi-structured interviews, non-participant observations and documents. A multiple triangulation technique: data triangulation and within-methods triangulation were employed in order to gain an in-depth understanding of the topic. The data were analysed using thematic analysis. Findings: The emergency care workflow consisted of multidisciplinary ED team members’ work processes. These work processes were comprised of collaborative clinical and non-clinical tasks and activities in delivering care treatment governed and defined by time-related activities, organisational rules, exceptions and variability. The workflow was supported by both computerised systems and non-computerised information artefacts, such as non-electronic whiteboards and paper-based records and forms, which needed to be used in conjunction with each other. Additionally, the hybrid implementation had also been utilised to support collaborative work of the clinicians and non-clinicians, hence giving the implication that HIT systems should not be designed as purely technical system focusing on single users, but also as a collaborative work system. Conclusion: An ED workflow consists of interrelated care processes, clinical and non-clinical processes. These processes are executed semi-autonomously by clinicians and non-clinicians and governed by time-related organisational constraints, variable and exception-filled, relying on hybrid information architecture. The architecture presented workflow with a number of integration issues. However, its implementation does not only support the functionalities for the delivery of emergency care processes but also the collaborative practices of the clinicians and non-clinicians