Ethnographic analysis on the use of the electronic medical record for clinical handoff

Understanding the impacts of health information systems on patient flow management: A systematic review across several decades of research

Background

Patient flow describes the progression of patients along a pathway of care such as the journey from hospital inpatient admission to discharge. Poor patient flow has detrimental effects on health outcomes, patient satisfaction and hospital revenue. There has been an increasing adoption of health information systems (HISs) in various healthcare settings to address patient flow issues, yet there remains limited evidence of their overall impacts.

Objective

To systematically review evidence on the impacts of HISs on patient flow management including what HISs have been used, their application scope, features, and what aspects of patient flow are affected by the HIS adoption.

Methods

A systematic search for English-language, peer-review literature indexed in MEDLINE and EMBASE, CINAHL, INSPEC, and ACM Digital Library from the earliest date available to February 2022 was conducted. Two authors independently scanned the search results for eligible publications, and reporting followed the PRISMA guidelines. Eligibility criteria included studies that reported impacts of HIS on patient flow outcomes. Information on the study design, type of HIS, key features and impacts was extracted and analysed using an analytical framework which was based on domain-expert opinions and literature review.

Results

Overall, 5996 titles were identified, with 44 eligible studies, across 17 types of HIS. 22 studies (50%) focused on patient flow in the department level such as emergency department while 18 studies (41%) focused on hospital-wide level and four studies (9%) investigated network-wide HIS. Process outcomes with time-related measures such as ‘length of stay’ and ‘waiting time’ were investigated in most of the studies. In addition, HISs were found to address flow problems by identifying blockages, streamlining care processes and improving care coordination.

Conclusion

HIS affected various aspects of patient flow at different levels of care; however, how and why they delivered the impacts require further research.

The Effect of the Electronic Health Record on Interprofessional Practice: A Systematic Review

BACKGROUND

Interprofessional practice and teamwork are critical components to patient care in a complex hospital environment. The implementation of electronic health records (EHRs) in the hospital environment has brought major change to clinical practice for clinicians which could impact interprofessional practice.

OBJECTIVES

The aim of the study is to identify, describe, and evaluate studies on the effect of an EHR or modification/enhancement to an EHR on interprofessional practice in a hospital setting.

METHODS

Seven databases were searched including PubMed, Scopus, Web of Science, CINAHL, Cochrane, EMBASE, and ACM Digital Library until November 2021. Subject heading and title/abstract searches were undertaken for three search concepts: "interprofessional" and "electronic health records" and "hospital, personnel." No date limits were applied. The search generated 5,400 publications and after duplicates were removed, 3,255 remained for title/abstract screening. Seventeen studies met the inclusion criteria and were included in this review. Risk of bias was quantified using the Quality Assessment Tool for Studies with Diverse Designs. A narrative synthesis of the findings was completed based on type of intervention and outcome measures which included: communication, coordination, collaboration, and teamwork.

RESULTS

The majority of publications were observational studies and of low research quality. Most studies reported on outcomes of communication and coordination, with few studies investigating collaboration or teamwork. Studies investigating the EHR demonstrated mostly negative or no effects on interprofessional practice (23/31 outcomes; 74%) in comparison to studies investigating EHR enhancements which showed more positive results (20/28 outcomes; 71%). Common concepts identified throughout the studies demonstrated mixed results: sharing of information, visibility of information, closed-loop feedback, decision support, and workflow disruption.

CONCLUSION

There were mixed effects of the EHR and EHR enhancements on all outcomes of interprofessional practice, however, EHR enhancements demonstrated more positive effects than the EHR alone. Few EHR studies investigated the effect on teamwork and collaboration.

Information handoffs in critical care and their implications for information quality: A socio-technical network approach

OBJECTIVE

The design of health ICTs, as well as human factors, have been shown to influence patient information quality. The aim of this study was to understand how patterns of interaction between these factors influence information quality aspects in a critical care environment.

METHOD

We conducted an ethnographic study of socio-technical information handoffs in a critical care unit. Data collection methods included non-participant observations and semi-structured interviews. Methodological principles from network analysis (SNA, VNA) were used to develop visual network diagrams, as well as to analyze the composition of the information network and its influence on patient information quality.

RESULTS

The network patterns that emerged uncover that human actors have many information processing and dissemination roles at the critical care unit. However, ICTs play key network roles, acting as information intermediaries and gatekeepers. We further identify three types of information handoffs in the critical care environment - human-human, human-ICT and ICT-human. On the one hand, we find that human-human and ICT-human handoffs influence contextual and intrinsic aspects of patient information, such as information completeness and accuracy. On the other hand, human-ICT handoffs influence information accessibility and representational quality, such as consistency and interpretability.

DISCUSSION

The results suggest that standardizing change of shift handoff communication may not be sufficient to prevent information decay in complex care trajectories. In particular, we argue that ensuring information consistency and interpretability across disciplines and professions is as important as ensuring information completeness and accuracy during change of shift handoffs. ICT and workflow design opportunities are discussed as means to address overlapping or conflicting information needs across disciplines and professions, increase information consistency, and reduce information redundancy across the network.

Emergency care under the magnifying glass: a review of ethnographic studies in the scientific literature on hospital emergency services

The article presents a review of ethnographic studies in the scientific literature on hospital emergency services, with the objective of systematizing the studies and their principal findings, referring to the health-disease-healthcare process in hospital emergency services from an ethnographic perspective. An integrative literature review was performed of studies published in Argentine and international indexed journals and in the following electronic databases: PubMed, VHL, Scopus, Redalyc, and SciELO. The corpus of the analysis consisted of a total of 69 articles, which were submitted to content analysis, having identified the following analytical dimensions: quality of care, communication and bonds, subjectivity, application of information technologies, methodological reflection, patients' experiences and practices, decision-making, and violence. The results allowed identifying a process that differs from guidelines and protocols, in which healthcare workers' subjective aspects, communication and interpersonal relations, and working conditions shape, orient, and condition the treatment and care provided in the hospital. The article thus highlights the approach to subjective aspects in health studies, to understand not only health workers' perspectives and experiences but also the persistent barriers to providing better quality of care, complexifying a problem ignored by a large share of the analyses.

Front-line nurses' perceptions of intra-hospital handover

AIM AND OBJECTIVE

To explore nurses' perceptions of factors that help or hinder intra-hospital handover.

BACKGROUND

Miscommunication during clinical handover is a leading cause of clinical incidents in hospitals. Intra-hospital nursing handover between the emergency department and inpatient unit is particularly complex.

DESIGN

A descriptive, qualitative study. This research adheres to the consolidated criteria for reporting qualitative research.

METHODS

Forty-nine nurses participated in group interviews, which were analysed using inductive content analysis.

RESULTS

Three categories emerged: (a) "lacking clear responsibilities for who provides handover"; (b) "strategies to ensure continuity of information"; and (c) "strained relationships during handover."

CONCLUSIONS

Intra-hospital handover requires clear processes, to promote high-quality information sharing. Ensuring these processes are broad and acceptable across units may ensure nurses' needs are met. Relational continuity between nurses is an important consideration when improving intra-hospital handover.

RELEVANCE TO CLINICAL PRACTICE

Nursing managers are optimally positioned to enhance intra-hospital handover, by liaising and enforcing standardisation of processes across units. Nurse managers could promote intra-unit activities that foster front-line nurses' communication with each other, to encourage problem-solving and partnerships.

Using focused ethnography to explore and describe the process of nurses' shift reports in a psychiatric intensive care unit

AIMS AND OBJECTIVES

To explore and describe the cultural routine of shift reports among nursing staff in a psychiatric intensive care unit and further to develop a taxonomic, thematic and theoretical understanding of the process.

BACKGROUND

Lack of communication among healthcare staff is associated with risks for medical errors. Thus, handovers and shift reports are an essential and integral routine among nurses to pass on information about the patients' health status. Previous studies within the field have highlighted the benefits of structured reporting tools. However, shift reports as a cultural activity within the nursing tradition have been given less attention, not the least in psychiatric care.

METHODS

Focused ethnography was used. The data comprised 20 observational sessions. The observations ranged over a time span of 5 months and were conducted in a psychiatric intensive care unit in Sweden.

RESULTS

The process of shift reports encompassed the following three phases: (a) getting settled, (b) giving the report and (c) engaging in the aftermath. The results demonstrate that the phases entail different cultural activities, which take place in different areas of the ward and that the level of formality varied.

CONCLUSIONS

Shift reports are not an isolated event with clear boundaries. The study enriches the understanding of shift reports as a "fuzzy process". The individual phases were found to be tied to cultural connotations, such as activities, places and roles with certain meanings for staff members.

RELEVANCE TO CLINICAL PRACTICE

The new insights are useful for nurses in overcoming an uncritical adoption of the biomedical tradition regarding pace and tone during shift reports. The reporting nurse has the potential to transform shift reports from a monologue with a foreclosed style to a more dialogical interaction with colleagues that focuses on the patients' needs rather than the needs of staff.