Insight into Electronic Health Record (EHR) workarounds increases patient safety

Insight into Electronic Health Record (EHR) workarounds can help healthcare organizations to increase patient safety as well as the quality and efficiency of care. In order to achieve this, the entire care provision system must be included. This is one of the conclusions reached by Dr. Vincent Blijleven in his dissertation titled “A Sociotechnical Perspective on Workarounds Emerging from Electronic Health Record System Usage in an Academic Hospital Setting”, for which he received his doctorate from Nyenrode Business Universiteit on Wednesday March 28, 2018.

As a case study for his research, Blijleven selected an EHR that is used in an academic hospital. “An EHR is also referred to as the backbone of a modern hospital organization. Due to the complexity of an academic hospital, the system must meet a multitude of requirements in different specialized areas of healthcare. Because it is difficult to have an EHR fulfill all of these – at times conflicting – requirements, we see that EHR users develop their own workarounds.”

Workarounds are procedures created by EHR users to deal with, for example, limitations in the EHR or their limited knowledge of the system. In this way, workarounds provide the user with alternative solutions to circumvent such limitations and still achieve the desired result. Blijleven: “Although workarounds are sometimes advantageous, they often also lead to information and work protocols that are unstable, unreliable and unavailable, which can in turn affect the safety, quality and efficiency of care. This makes identifying and resolving workarounds a valuable step for EHR optimization.”

Cultural shift

To effectively resolve workarounds, the workarounds must be studied from more than just a technical perspective, according to Blijleven. Many workarounds are not just a response to technical shortcomings, but also arise from user-related factors. Blijleven explains that EHR users often conceal their workarounds out of fear of retaliation, should anything ever go wrong as the result of a workaround. This causes them to stay under the radar. “Hospital management needs to work on an open organizational culture in which it is possible to talk about workarounds and share knowledge. Shortcomings in an EHR can then be brought to light and used as a point of departure for valuable EHR optimization measures. It is also important in this regard to identify the scope of workarounds. Is the care provider the only one to notice the impact? Does it affect the patient, the entire organization, or a combination of both? And what are the consequences?”

Blijleven advises forming teams with stakeholders from different parts and layers of the organization in order to identify and analyze workarounds. Decisions can then be made regarding the most effective approach to resolve each workaround. Blijleven finally emphasizes that EHR users should be treated as a starting point: “By familiarizing users with the EHR at an early stage, for instance through a minimum viable product, many knowledge-related workarounds can be prevented. This speeds up the process of getting the system to be used safely, effectively and efficiently.”

Framework

Blijleven’s aim was to investigate possibilities for using EHRs more safely, more effectively and more efficiently. He concludes, among other things, that despite the proven added value of EHRs, there is still a lot of room for improvement – specifically in the area of workarounds. He therefore developed a framework for identifying, analyzing and resolving workarounds. This framework should take EHRs in hospitals to a higher level.

As workarounds also occur in other sectors and types of applications, the research method and results of this study are applicable in a wide range of contexts.

The summary of Dr. Vincent Blijleven’s thesis “A Sociotechnical Perspective on Workarounds Emerging from Electronic Health Record System Usage in an Academic Hospital Setting” can be downloaded in Dutch and English here.