A Fit between Clinical Workflow and Health Care Information Systems: Not waiting for Godot but making the journey

Health care has long suffered from inefficiencies due to the fragmentation of patient care information and the lack of coordination between health professionals [1]. Health care information systems (HISs) have been lauded as tools to remedy such inefficiencies [2, 3]. The primary idea behind the support of their implementation in health care is that these systems support clinical workflow and thereby decrease medical errors [2]. However, their introduction to health care settings have been accompanied by a transformation of the way their primary users, care providers, carry out clinical tasks and establish or maintain work relationships [4]. Studies have shown that these transformations have not always been productive [5, 6]

THE ROLE OF WORKAROUNDS DURING AN OPENSOURCE ELECTRONIC MEDICAL RECORD SYSTEM IMPLEMENTATION

A significant degree of customization of medical information technology is required to effectively integrate the promise of IT with the diversity and complexity of medical work. In the absence of such customizations, dissatisfaction and resistance toward the system arise. Indeed, the complexity of the medical work and the inability of software to tailor to the diverse medical practices may explain the limited diffusion of health information systems especially in North America. We study the role of workarounds during an open-source Electronic Medical Record System (EMR) implementation at a medium-size urgent care clinic in a major Canadian city. We found that the technology appropriation process involved the evolving of number of non-trivial workarounds in order to match the EMR to medical work. The emergence of workarounds is conceptualized as a knowledge creation and integration process. This perspective allows us to look at the antecedents and the change dynamics of workarounds in the clinic. Furthermore diverging from the negative view toward workarounds, we discuss the importance of incorporating workarounds during and following system development. The workaround perspective shed the light on how users’ behavior can be channeled into a constructive development effort. This paper contributes by examining the workaround of medical practitioners using an open-source electronic medical record system as well as offering a knowledge perspective for the study of EMR appropriation

A normative method to analyse workarounds in a healthcare environment: motivations, consequences, and constraints

Healthcare information systems have the potential to enhance productivity, lower costs, and reduce medication errors by automating business processes. However, various issues such as system complexity and system abilities in a relation to user requirements as well as rapid changes in business needs have an impact on the use of these systems. In many cases failure of a system to meet business process needs has pushed users to develop alternative work processes (workarounds) to fill this gap. Some research has been undertaken on why users are motivated to perform and create workarounds. However, very little research has assessed the consequences on patient safety. Moreover, the impact of performing these workarounds on the organisation and how to quantify risks and benefits is not well analysed. Generally, there is a lack of rigorous understanding and qualitative and quantitative studies on healthcare IS workarounds and their outcomes. This project applies A Normative Approach for Modelling Workarounds to develop A Model of Motivation, Constraints, and Consequences. It aims to understand the phenomenon in-depth and provide guidelines to organisations on how to deal with workarounds. Finally the method is demonstrated on a case study example and its relative merits discussed

Nurses' workarounds in acute healthcare settings: A scoping review

Background: Workarounds circumvent or temporarily 'fix' perceived workflow hindrances to meet a goal or to achieve it more readily. Behaviours fitting the definition of workarounds often include violations, deviations, problem solving, improvisations, procedural failures and shortcuts. Clinicians implement workarounds in response to the complexity of delivering patient care. One imperative to understand workarounds lies in their influence on patient safety. This paper assesses the peer reviewed empirical evidence available on the use, proliferation, conceptualisation, rationalisation and perceived impact of nurses' use of workarounds in acute care settings. Methods. A literature assessment was undertaken in 2011-2012. Snowballing technique, reference tracking, and a systematic search of twelve academic databases were conducted to identify peer reviewed published studies in acute care settings examining nurses' workarounds. Selection criteria were applied across three phases. 58 studies were included in the final analysis and synthesis. Using an analytic frame, these studies were interrogated for: workarounds implemented in acute care settings by nurses; factors contributing to the development and proliferation of workarounds; the perceived impact of workarounds; and empirical evidence of nurses' conceptualisation and rationalisation of workarounds. Results: The majority of studies examining nurses' workarounds have been published since 2008, predominantly in the United States. Studies conducted across a variety of acute care settings use diverse data collection methods. Nurses' workarounds, primarily perceived negatively, are both individually and collectively enacted. Organisational, work process, patient-related, individual, social and professional factors contribute to the proliferation of workarounds. Group norms, local and organisational culture, 'being competent', and collegiality influence the implementation of workarounds. Conclusion: Workarounds enable, yet potentially compromise, the execution of patient care. In some contexts such improvisations may be deemed necessary to the successful implementation of quality care, in others they are counterproductive. Workarounds have individual and cooperative characteristics. Few studies examine nurses' individual and collective conceptualisation and rationalisation of workarounds or measure their impact. The importance of displaying competency (image management), collegiality and organisational and cultural norms play a role in nurses' use of workarounds. © 2013 Debono et al.; licensee BioMed Central Ltd

Supernurse:Nurses' workarounds informing the design of interactive technologies for home wound care

The increasing aging population needing homecare is leading to additional clinical work for homecare nurses. Wound care and documentation are substantial components of this work required to monitor patients and make appropriate clinical decisions. However, due to barriers in the systems that nurses are expected to use, and context of their activities, they create and use workarounds to get their job done. In this study, the most common themes of workarounds were identified and used to inform design iterations of a wound documentation application: SuperNurse. The exploratory and experimental design iterations involved homecare nurses, who expressed: curiosity, leading to further reflection; frustration, leading to identifying problems; and surprise, leading to identifying useful and easy to use designs. We found that nurse-centred design, informed by workarounds, led to using mobile, wearable, and speech recognition technology and improving ease of use and usefulness in SuperNurse

Theory of Workarounds

Although mentioned frequently in the organization, management, public administration, and technology literatures, workarounds are understudied and undertheorized. This article provides an integrated theory of workarounds that describes how and why workarounds are created. The theory covers most types of workarounds and most situations in which workarounds occur in operational systems. This theory is based on a broad but useful definition of workaround that clarifies the preconditions for the occurrence of a workaround. The literature review is organized around a diagram that combines the five “voices” in the literature of workarounds. That diagram is modeled after the diagram summarizing Orton and Weick’s [1990] loose coupling theory, which identified and combined five similar voices in the literature about loose coupling. Building on that basis, the theory of workarounds is a process theory driven by the interaction of key factors that determine whether possible workarounds are considered and how they are executed. This theory is useful for classifying workarounds and analyzing how they occur, for understanding compliance and noncompliance to methods and management mandates, for incorporating consideration of possible workarounds into systems analysis and design, and for studying how workarounds and other adaptations sometimes lead to larger planned changes in systems

Human factors in mental healthcare : A work system analysis of a community-based program for older adults with depression and dementia

Mental healthcare is a critical but largely unexplored application domain for human factors/ergonomics. This paper reports on a work system evaluation of a home-based dementia and depression care program for older adults, the Aging Brain Care program. The Workflow Elements Model was used to guide data collection and analysis of 59 h of observation, supplemented by key informant input. We identified four actors, 37 artifacts across seven types, ten action categories, and ten outcomes including improved health and safety. Five themes emerged regarding barriers and facilitators to care delivery in the program: the centrality of relationship building; the use of adaptive workarounds; performance of duplicate work; travel and scheduling challenges; and communication-related factors. Findings offer new insight into how mental healthcare services are delivered in a community-based program and key work-related factors shaping program outcomes