The influence of electronic health record use on collaboration among medical specialties

Background: One of the main objectives of Electronic Health Records (EHRs) is to enhance collaboration among healthcare professionals. However, our knowledge of how EHRs actually affect collaborative practices is limited. This study examines how an EHR facilitates and constrains collaboration in five outpatient clinics. Methods: We conducted an embedded case study at five outpatient clinics of a Dutch hospital that had implemented an organization-wide EHR. Data were collected through interviews with representatives of medical specialties, administration, nursing, and management. Documents were analyzed to contextualize these data. We examined the following collaborative affordances of EHRs: (1) portability, (2) co-located access, (3) shared overviews, (4) mutual awareness, (5) messaging, and (6) orchestrating. Results: Our findings demonstrate how an EHR will both facilitate and constrain collaboration among specialties and disciplines. Affordances that were inscribed in the system for collaboration purposes were not fully actualized in the hospital because: (a) The EHR helps health professionals coordinate patient care on an informed basis at any time and in any place but only allows asynchronous patient record use. (b) The comprehensive patient file affords joint clinical decision-making based on shared data, but specialty- and discipline-specific user-interfaces constrain mutual understanding of that data. Moreover, not all relevant information can be easily shared across specialties and outside the hospital. (c) The reduced necessity for face-to-face communication saves time but is experienced as hindering collective responsibility for a smooth workflow. (d) The EHR affords registration at the source and registration of activities through orders, but the heightened administrative burden for physicians and the strict authorization rules on inputting data constrain the flexible, multidisciplinary collaboration. (e) While the EHR affords a complete overview, information overload occurs due to the parallel generation of individually owned notes and the high frequency of asynchronous communication through messages of varying clinical priority. Conclusions: For the optimal actualization of EHRs' collaborative affordances in hospitals, coordinated use of these affordances by health professionals is a prerequisite. Such coordinated use requires organizational, technical, and behavioral adaptations. Suggestions for hospital-wide policies to enhance trust in both the EHR and in its coordinated use for effective collaboration are offered

Facilitating and constraining influences of an Electronic Health Record on collaboration among medical specialties

Context:Collaboration among health professionals of the medical specialties involved in a patient stream is considered a key factor for achieving high quality clinical care. One major reason to implement comprehensive Electronic Health Records is to enhance such collaboration. However, in practice it appears that EHRs both promote and hinder collaboration, rendering EHR-enabled collaboration context dependent. Systematic knowledge on how the different EHR features actually affect collaborative practices is limited. Therefore, we are interested how the ways healthcare professionals communicate, and eventually collaborate, are influenced by the affordances of an EHR. In this study we examine facilitating and constraining influences on the actualization of an EHR’s inscribed collaborative affordances in five outpatient clinics.Method:We conducted an embedded case study at five multidisciplinary outpatient clinics of a Dutch hospital that recently implemented an organization-wide EHR. Data collection comprised semi-structured interviews with representatives of medical specialties, medical administration, nursing, and management. Documents were analyzed to contextualize these data. We examined the following six collaborative affordances of EHRs: (1) portability, (2) collocated access, (3) shared overview, (4) mutual awareness, (5) messaging and (6) orchestrating. Results and Discussion:Our findings unravel how an EHR can simultaneously have facilitating as well as constraining influences on collaboration between specialties and disciples. Consequently, collaborative affordances inscribed in the system were not fully actualized in the focal hospital. (a) The EHR helps health professionals in coordinating patient care on an informed basis any time and any place, as long as their patient record use is a-synchronous. (b) The comprehensive patient file affords joint clinical decision making based on shared data, but specialty- and discipline-specific user-interfaces constrain mutual understanding of that data. Moreover, not all materials can be easily shared across specialties. (c) Reduced necessity of face-to-face communication saves time, but is experienced to hinder the collective responsibility for a smooth workflow. (d) The EHR affords registration at the source and full registration of activities through orders, yet the heightened administrative burden for physicians and the strict authorizations constrain the EHR affordance of flexible, multidisciplinary collaboration. (e) While the EHR affords a complete overview, information overload occurs due to the parallel generation of individually owned notes and the high frequency of a-synchronous communication through messages varying in clinical priority.Conclusions:For the full actualization of EHRs’ inscribed collaborative affordances in hospitals, health professionals’ coordinated use of these affordances is a prerequisite. To enable such coordinated use organizational, technical, and behavioral adaptations are required. Hospital-wide policies to enhance trust both in the EHR and in its coordinated use for effective collaboration are suggested

Postoperative Delirium in Individuals Undergoing Transcatheter Aortic Valve Replacement : A Systematic Review and Meta-Analysis

Objectives: To evaluate the incidence of in-hospital postoperative delirium (IHPOD) after transcatheter aortic valve replacement (TAVR). Design: Systematic review and meta-analysis. Setting: Elective procedures. Participants: Individuals undergoing TAVR. Measurements: A literature search was conducted in PubMed, Embase, BioMedCentral, Google Scholar, and the Cochrane Central Register of Controlled Trials (up to December 2017). All observational studies reporting the incidence of IHPOD after TAVR (sample size > 25) were included in our meta-analysis. The reported incidence rates were weighted to obtain a pooled estimate rate with 95% confidence interval (CI). Results: Of 96 potentially relevant articles, 31 with a total of 32,389 individuals who underwent TAVR were included in the meta-analysis. The crude incidence of IHPOD after TAVR ranged from 0% to 44.6% in included studies, with a pooled estimate rate of 8.1% (95% CI=6.7–9.4%); heterogeneity was high (Q = 449; I = 93%; p heterogeneity <.001). The pooled estimate rate of IHPOD was 7.2% (95% CI=5.4–9.1%) after transfemoral (TF) TAVR and 21.4% (95% CI=10.3–32.5%) after non-TF TAVR. Conclusion: Delirium occurs frequently after TAVR and is more common after non-TF than TF procedures. Recommendations are made with the aim of standardizing future research to reduce heterogeneity between studies on this important healthcare problem. J Am Geriatr Soc 66:2417–2424, 2018