The impact of using computer decision-support software in primary care nurse-led telephone triage:Interactional dilemmas and conversational consequences

Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse-caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting 'telling cases' of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the 'interactional workability' of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care

Simulation Genres and Student Uptake: The Patient Health Record in Clinical Nursing Simulations

Drawing on fieldwork, this article examines nursing students’ design and use of a patient health record during clinical simulations, where small teams of students provide nursing care for a robotic patient. The student-designed patient health record provides a compelling example of how simulation genres can both authentically coordinate action within a classroom simulation and support professional genre uptake. First, the range of rhetorical choices available to students in designing their simulation health records are discussed. Then, the article draws on an extended example of how student uptake of the patient health record within a clinical simulation emphasized its intertextual relationship to other genres, its role mediating social interactions with the patient and other providers, and its coordination of embodied actions. Connections to students’ experiences with professional genres are addressed throughout. The article concludes by considering initial implications of this research for disciplinary and professional writing courses

The Promise of Health Information Technology: Ensuring that Florida's Children Benefit

Substantial policy interest in supporting the adoption of Health Information Technology (HIT) by the public and private sectors over the last 5 -- 7 years, was spurred in particular by the release of multiple Institute of Medicine reports documenting the widespread occurrence of medical errors and poor quality of care (Institute of Medicine, 1999 & 2001). However, efforts to focus on issues unique to children's health have been left out of many of initiatives. The purpose of this report is to identify strategies that can be taken by public and private entities to promote the use of HIT among providers who serve children in Florida

Taking Note: A Design Solution for Physician Documentation to Balance the Benefits of Handwritten Notes and Electronic Health Records

Master of Design in Integrative DesignUniversity of Michiganhttps://deepblue.lib.umich.edu/bitstream/2027.42/136865/1/THo_2017_MDes-Thesis.pd

Pediatric Nurses\u27 Perspectives on Medication Teaching in a Children\u27s Hospital

Purpose To explore inpatient pediatric nurses\u27 current experiences and perspectives on medication teaching. Design and Methods A descriptive qualitative study was conducted at a Midwest pediatric hospital. Using convenience sampling, 26 nurses participated in six focus groups. Data were analyzed in an iterative group coding process. Results Three themes emerged. 1) Medication teaching is an opportunity. 2) Medication teaching is challenging. Nurses experienced structural and process challenges to deliver medication teaching. Structural challenges included the physical hospital environment, electronic health record, and institutional discharge workflow while process challenges included knowledge, relationships and interactions with caregivers, and available resources. 3) Medication teaching is amenable to improvement. Conclusion Effective medication teaching with caregivers is critical to ensure safe, quality care for children after discharge. Nursing teaching practices have not changed, despite advances in technology and major changes in hospital care. Nurses face many challenges to conduct effective medication teaching. Improving current teaching practices is imperative in order to provide the best and safest care. Practice Implications This study generated knowledge regarding pediatric nurses\u27 teaching practices, values and beliefs that influence teaching, barriers, and ideas for how to improve medication teaching. Results will guide the development of targeted interventions to promote successful medication teaching practices

People, Technology and Work Practices: Understanding the Processes of Sensemaking When Using IT in a Nursing Context

Information Technology (IT) usage is increasingly focused on interaction processes rather than data storage and transaction. This change fundamentally transforms work practices, and these practices in interplay with human agents and technology in turn affect the boundaries for scope of action. In this paper, we explore nurses’ use of Electronic Patient Records (EPRs) for sensemaking and other elucidating processes that support, co- create, and mediate collective learning and social practice, thereby contributing to individual and organizational knowledge

Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

Background: The extensive and rapidly expanding research literature on electronic patient records (EPRs) presents challenges to systematic reviewers. This literature is heterogeneous and at times conflicting, not least because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. Aim: To map, interpret and critique the range of concepts, theories, methods and empirical findings on EPRs, with a particular emphasis on the implementation and use of EPR systems. Method: Using the meta-narrative method of systematic review, and applying search strategies that took us beyond the Medline-indexed literature, we identified over 500 full-text sources. We used ‘conflicting’ findings to address higher-order questions about how the EPR and its implementation were differently conceptualised and studied by different communities of researchers. Main findings: Our final synthesis included 24 previous systematic reviews and 94 additional primary studies, most of the latter from outside the biomedical literature. A number of tensions were evident, particularly in relation to: [1] the EPR (‘container’ or ‘itinerary’); [2] the EPR user (‘information-processer’ or ‘member of socio-technical network’); [3] organizational context (‘the setting within which the EPR is implemented’ or ‘the EPR-in-use’); [4] clinical work (‘decision-making’ or ‘situated practice’); [5] the process of change (‘the logic of determinism’ or ‘the logic of opposition’); [6] implementation success (‘objectively defined’ or ‘socially negotiated’); and [7] complexity and scale (‘the bigger the better’ or ‘small is beautiful’). Findings suggest that integration of EPRs will always require human work to re-contextualize knowledge for different uses; that whilst secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper, far from being technologically obsolete, currently offers greater ecological flexibility than most forms of electronic record; and that smaller systems may sometimes be more efficient and effective than larger ones. Conclusions: The tensions and paradoxes revealed in this study extend and challenge previous reviews and suggest that the evidence base for some EPR programs is more limited than is often assumed. We offer this paper as a preliminary contribution to a much-needed debate on this evidence and its implications, and suggest avenues for new research

The Effect of Standardized Photodocumentation on Coding of Pressure Injuries

Background and Purpose: Pressure injuries (PI) are prevalent and costly for hospitals. Hospitals implement different practices to accurately document PIs ranging from pen and paper to photodocumentation in electronic medical records (EMRs). In some instances, PIs that have been documented are not coded for billing and reporting. The purpose of this study is to determine if different documentation practices affect the number of coded PIs. Methods: Counts of coded PIs were collected from 2011- 2017 from two hospitals: a 500-bed acute care hospital (ACH) and a 42-bed acute rehabilitation hospital (ARH). A series of PI documentation practices were implemented over the course of the six years data were collected. The aim of the changes were to improve the accuracy of wound assessment, facilitate transparent and accurate reporting, and improve care. The four documentation practice time periods included 1) baseline, 2) PI photodocumentation with paper and all paper charting, 3) PI photodocumentation on paper and EMR for all other charting, and finally 4) all charting and documentation in the EMR. Results: In the 500-bed facility, a statistically significant difference was found in the mean number of PIs coded among the four documentation periods (F(3) = 45.460; p \u3c 0.001), with the highest number of PI’s reported during PI photodocumentation with paper and all paper charting. In the ARH there was a statistically significant difference in the average number of PIs among the four different documentation periods (Period 1-ARH Mean = 56, Period 2-ARH Mean = 31, SD = 11.3, Period 3-ARH Mean = 36.1, SD = 14.4, Period 4-ARH Mean = 58.7, SD = 11.3; F(3) = 5.994; p = 0.006). In post hoc analysis a significant difference between Period 2-ARH and Period 4-ARH (p = 0.036), as well as between Period 3-ARH and Period 4-ARH (p = 0.005) was observed. Discussion: Changes in documentation practice coincided with significant changes in the number of PIs being coded in the ACH and ARH. Improper or inaccurate documentation of PIs has the potential to result in inaccurate coding and therefore missed payment for services provided. More serious PIs that are not coded properly may cost the facility thousands of dollars in missed payments. Accurate assessment and subsequent coding of PIs ensures the facility is fairly compensated for services provided

Physician Practice Variation in Electronic Health Record Documentation.

Adoption of electronic health records (EHRs) was motivated by the expectation that they would improve quality and decrease costs of care. EHRs’ value, however, depends on how they are used, which likely explains the heterogeneous benefits observed in the literature. This dissertation uses mixed methods to explore a critical component of EHR use in primary care: variation in EHR documentation, defined as differences in how users record or remove information. The first chapter delineates a conceptual framework of variation in EHR documentation that includes five different forms of variation and five levels where the forms may materialize. This chapter focuses on potentially harmful variation by detailing how non-patient factors foster variation that interferes with clinical decision support, care coordination, and population health management, jeopardizing the efficient delivery of high-quality healthcare. The second chapter measures variation in one form of variation, completion of documentation, in a national sample of primary care practices. Using data from a major EHR vendor, this chapter finds differences in how variably providers complete fifteen different clinical documentation categories and identifies patient’s problems, the provider’s assessment and diagnosis, the social history, the review of systems, and communication about lab and test results as the most varied. The majority of variation exists across providers in the same practice, suggesting providers are making different decisions about documentation for comparable patients. The final chapter explores the context of this variation with semi-structured interviews, finding that variation in EHR documentation is perceived as a commonplace phenomenon resulting from a flexible EHR design that allows users to develop different documentation styles. Variation reportedly introduced inefficiencies into care delivery and created patient safety and care quality risks from missed or misinterpreted information. Respondents identified additional training, ongoing meetings, and improvements in EHR design as effective strategies to prevent harm. Widespread variation in EHR documentation can interfere with care delivery by obscuring the location and meaning of patient information. In order to realize gains from adopting EHRs, practices, vendors, and policymakers must collaboratively develop better interfaces and clearer guidelines to support their effective use.PHDHealth Services Organization & PolicyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/135900/1/grcohen_1.pd

Examining Electronic Medical Records System Adoption and Implications for Emergency Medicine Practice and Providers

This ethnographic research study documented the use and effects of an electronic medical records system (EMR) by healthcare providers working in a community hospital-based emergency room. Using data collected from participant observation, in-depth interviews, questionnaires, and hospital documents, the research findings suggest EMRs impinge providers’ agency, alter emergency room systems, affect communication patterns among providers, and exacerbate structurational divergence (SD) conditions. Findings suggest that providers’ attempts to regain lost agency tips the SD-nexus into an SD-cycle, characterized by negative communication spirals between providers. The discussion chapter examines the impact of EMRs on emergency room structures, system reproduction, providers’ workflow and communication patterns, patients’ experiences, and unintended consequences, and it expounds implications of the study with regard to what lessons learned from this analysis suggests might be best practices for hospitals and emergency rooms adopting EMRs