Investigating Barriers to Electronic Medical Record ...

Investigating Barriers to Electronic Medical Record Use during Collaborative Information Seeking Activities Arvind Karunakaran

Young Hee-Nam

Madhu Reddy

Pennsylvania State University University Park Pennsylvania, USA



[email protected]

[email protected]

[email protected]

Work in modern healthcare organizations is increasingly becoming collaborative. Such collaborative work is characterized not just by an increasing interdependence between different healthcare providers, but instead, among and across different providers, artifacts and activities [8, 18, 19]. In addition, healthcare settings are becoming information-intensive, but this information is fragmented across multiple providers, artifacts and systems[4]. Consequently, collaborative information seeking (CIS) has become an important aspect of medical work [9, 20]. Specifically, patient care teams tend to rely upon various artifacts and systems, such as Electronic Medical Records (EMRs), to collaboratively seek information across hierarchical, functional and occupational boundaries of the organization[1, 9]. However, despite their proven benefits, there are several challenges to using EMRs during CIS activities [14]. Although researchers have pointed out the rigid nature of EMRs and the difficulty of using EMRs during collaborative work activities[12, 16], very few of them have explicitly focused on its information seeking aspects. Even the ones that have focused on it perceived information seeking at an individual level, and conceptualized it as an intrinsically individual activity[4]. All of these had led researchers and developers overlooking CIS. As a consequence, these systems are designed to primarily support individual, and not collaborative, information seeking activities. The objective of this research study, therefore, is to identify the barriers associated with using EMRs during CIS activities. Previous CIS studies have identified triggers that cause patient care teams to collaborate when seeking information[19, 20]. In this study, we are interested in identifying barriers that hinder team members to collaborate when seeking information. By understanding these barriers, we can start to design EMR systems that could support, augment and facilitate better CIS. We employed qualitative research methods to understand how individuals within patient care teams use EMRs during CIS and what challenges they confront in the process. We conducted this study in the Emergency Department (ED) of a 500-bed teaching hospital. We used non-participant observations and semistructured interviews of patient care team members for collecting our data and for capturing the practices. Through our data analysis, we identified a set of barriers to using EMRs during CIS. These include a) clash of "technological frames", b) lack of collective affordances, c) fear of deviations and d) alert fatigues. From the findings, we highlight design implications, concerning incorporating collaborative affordances, such split-screens and

ABSTRACT Collaborative information seeking (CIS) is an intrinsic part of medical work. Patient care teams increasingly rely upon various systems, such as Electronic Medical Records (EMRs), to support collaborative information seeking across hierarchical, functional and occupational boundaries of the organization in order to enhance the quality of medical care. However, despite their proven benefits, there still are several challenges to using EMRs for CIS, in specific, and for collaborative work, in general. The objective of this research study, therefore, is to identify some of the barriers associated with using EMRs during CIS activities. We employed qualitative research methods to understand how individuals within patient care teams use EMRs during CIS and what challenges they confront in the process. We conducted this study in the Emergency Department of a 500-bed teaching hospital. We used non-participant observations and semistructured interviews of patient care team members for collecting our data and for capturing the practices. Through our data analysis, we identified a set of barriers to using EMRs during CIS. These include a) clash of "technological frames", b) lack of collective affordances, c) fear of deviations and d) alert fatigues. From the findings of our study, we highlight implications for designing EMR systems that could augment and facilitate better CIS.

Categories and Subject Descriptors H.3.3 [Information storage and Retrieval]: Information Search and Retrieval – search process.

General Terms Human Factors, Theory.

Keywords Collaboration, Work, Information Seeking, Electronic Medical Records, Barriers.

1. INTRODUCTION Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. To copy otherwise, or republish, to post on servers or to redistribute to lists, requires prior specific permission and/or a fee. IHI‟12, January 28–30, 2012, Miami, Florida, USA. Copyright 2012 ACM 978-1-4503-0781-9/12/01...$10.00

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collaborative search functionalities, into EMR systems, which could augment and facilitate better CIS.

related information sought by team members, in addition to the medical-related information. More importantly, they identified four triggers, namely information fragmentation, lack of immediately accessible information and complexity of information needs, which act as transition points from individual to collaborative information seeking.

2. EMRs IN COLLOBORATIVE INFORMATION SEEKING Ever since the Institute of Medicine recommended the use of EMRs for improving the quality of patient care, there has been increasing interest in implementing EMRs within healthcare organizations. EMRs are viewed as tools that would enable members of the patient care teams to easily store, retrieve and share patients‟ medical records across the hierarchical, functional and occupational boundaries of the healthcare organization. These, in turn, are said to vastly improve the quality of healthcare delivery, including increased efficiency, transparency and clarity in medical records, decreased medical errors, easy access to consolidated patients records, reduction in physicians mental workload, decrease in duplicated medical tests as well as reduced staff time in locating and pulling information from patient files [10, 12, 16]. Despite these proven benefits, researchers have documented several challenges to EMRs. These include, high initial implementation costs, ongoing maintenance costs, privacy and confidentiality concerns, interoperability issues, rigid structure, inadequate functionalities and such[1, 9, 14]. Though researchers have pointed out the barriers to the adoption of EMRs as well as the rigid nature of EMRs in constraining medical work [12. 16], very few of them have explicitly focused on its „collaboration‟ and „information seeking‟ aspects. That is, the role of EMRs in enabling and constraining collaborative information seeking (CIS) activities has been overlooked. Given that CIS is an integral part of medical work [18], it is important to understand the role played by EMRs in augmenting CIS.

2.2 Research Question These studies, although increased our understanding of CIS, have overlooked a number of crucial aspects. One, the role of artifacts and systems, such as EMRs have not been explicitly focused. Two, we now know more about what triggers CIS during medical work, but we still do not know much about what hinders CIS. Consequently, we had the following research question for this study: What hinders patient care teams from using EMRs for collaborating while looking for information? [i.e. What are the barriers to using EMRs during CIS activities?] Understanding the barriers to using EMRs during CIS would help us to design EMR systems that could not only support individual, but also collaborative, information seeking.

3. METHODS Since the nature of our research question is open-ended, and the phenomenon under study is nascent and not-well understood, qualitative methods were used for data collection and analysis. Qualitative methods are deemed appropriate for this study, since the research goal is to understand the underlying factors and practices that hinder the usage of EMRs during CIS. As Edmondson and McManus [5] suggest, qualitative method could be especially useful when it comes to uncovering factors that underlie the emergence of a phenomenon.

3.1 Data Collection

2.1 Past research on CIS in healthcare

A grounded, interpretive approach that could emphasize the participants‟ point of view was adopted for this research study. We decided to choose a naturalistic setting to maximize the realism of the context [11]. The study was conducted in the ED of a 500-bed teaching hospital in northeastern United States. The ED has approximately 50,000 visits per year and was supported by three to four attending physicians, several residents, and upon 17 staff nurses who are managed by a charge nurse. We did a total of two visits to the field site to collect our data. We used non-participant observations and semi-structured interviews for collecting our data. In order to collect the richest possible data, we iteratively performed data collection and analysis. We employed theoretical sampling [7] to identify key informants. Data collection and analysis unfolded in three overlapping stages. At the initial stage, we conducted an in-depth interview with the Chief Medical Information Officer (CMIO) of the hospital. We identified the broad set of problems and issues concerning the implementation and usage of EMRs within the hospital organization, in general, and within the emergency department, in specific. We also conducted non-participant observations within the ED to get a real sense of how EMRs are deployed and used “in the wild”. At the second stage, we identified a set of key informants (1 resident, 2 nurses, 1 physician) with whom we conducted semi-structured interviews. We probed for responses concerning how they perceived EMRs, how they used EMRs during CIS, what challenges they faced in the process and more. Later, we analyzed the previously collected data to understand the emergent themes, and then structured our subsequent interview questions based on the above collected data. Then, during the

We define CIS as the activity in which “two or more individuals work together to seek needed information in order to satisfy a goal”. CIS may involve a variety of systems, people, and channels in order to address the information need. Early CIS researchers conducted field studies to understand the features and contingencies of the healthcare context within which CIS happens. For example, Gorman [8] looked at how team members in an intensive care unit worked together to seek and share the needed information. One of the key findings from their study suggested the importance of binding different sources of information together, in order to address a specific request/question from a team member. Reddy and Dourish [18] conducted a study in the medical domain, where they described the role work rhythms plays during the collaborative information seeking practices of team members. Team members who understood the work rhythm of the unit could collaborate and seek information in a “just in time” fashion. Reddy and Spence‟s [20] field study of a multidisciplinary patient care team in an emergency department provided some initial answers on what triggered team members to collaborate when looking for information. They found three major triggers, namely lack of expertise, a lack of immediately accessible information, and complexity of information need, that made people to collaborate when looking for information. Finally, Reddy and Jansen‟s [19] empirical study of two healthcare teams have provided important initial insights about CIS. They identified seven categories of team information needs, and observed that there was a large percentage of organizational2

third stage, we asked highly-specific questions to a set of participants (1 intern, 1 nurse, 2 physicians), aimed at explicating the themes that emerged previously. In sum, we did a total of nine semi-structured interviews. These interviews, along with observational records and field notes, formed the crux of our data.

information storage or transfer tools, but as platforms for orchestrating end-to-end healthcare delivery. I think that general clinicians who are not, at least, as into it as I am, or others like me are into it, would describe an EMR, generally, as a record of a patient that is electronic. And they wouldn't go into... From their perspective, it would be their documentation, and maybe some results. To a savvy end user or CMIO types, it is a thousand times more than that. It's really the home of the patient's medical care, because...and I won't go into too much detail about this, their models of practice have changed over decades. Their models of practice nowadays are very much driven by the record, whereas in decades past it was driven by the patient-physician relationship.(#CMIO, verbatim1) These differing perceptions affected the way team members used EMRs, which, turn, impacted their CIS. For example, members who perceived EMRs as „information storage‟ tools use them like an archival repository for depositing patient-related information after the completion of work, as opposed to using them for constant sharing and dissemination of patient-related information during the moment of work. Similarly, members who view EMRs as „information transfer‟ tools would use them for sharing and disseminating patient information, but would largely ignore its persistence and archival functionalities. When these people with differing technological frames are brought together, CIS efforts are hindered due to the variance in their usage of technology.

3.2 Data Analysis Data was inductively analyzed, by adhering to the guidelines specified for naturalistic inquiry [11]. We were not allowed to record all but one interview due to privacy concerns. However, we took extensive notes during the interviews. These notes helped us to record the participant responses. We immediately analyzed the notes by adhering to the “24-hour rule”, and recorded them in a structured format for subsequent detailed analysis. We used a constant comparative method [7] to analyze the data. Responses were coded and analyzed by two independent coders. We followed Charmaz‟s [3] approach to data coding. Charmaz‟s approach to data coding unfolds through sequence of three major steps, namely initial coding, focused coding, and theoretical coding [3]. The first step in the process is “initial coding”, where concepts are uncovered, named and developed. Responses were coded on the basis of “in vivo” codes – phrases and terms offered by the informants - in order to arrive at first-order categories. Data was analyzed line-by-line to arrive at initial codes and categories. These links lead to clusters of second-order themes. The final step, theoretical coding, was used to strengthen or dismiss the emerging findings, and to tie it back to extant literature. These final steps lead to a collapse of second-order themes onto overarching aggregate dimensions. We had less than 12% disagreement rate, ensuring the credibility of the research study[11].

4.2 Lack of Collective Affordances In addition to the clash of technological frames, we found that lack of collective affordances too posed a major constraint on CIS. Gibson [6] introduced the term “affordance” to explicate upon the „action possibilities‟ that is latent within an artifact. That is, the term was used to suggest the features and qualities that are inherent within an artifact that “affords” its observers to use it in multitude of ways depending on how they view that artifact[6]. In corollary, a lack of appropriate affordances would constrain the usage of that artifact. In the case of EMRs, there was a lack of appropriate affordances not at the individual level, but at the collective level. That is, the features of EMRs do not “afford” its observers the ability to use it for collaborative activities. I want to use it… I could use it alone.. but I don’t see that there is a way of using it for sharing stuff or looking for stuff with, say, another person.. even if we could, we could only do it separately, and not together. And definitely, not in parallel. (#physician 2, from written notes) This lack of collective affordances constrains people from collaborating while looking for information. In other word, the look and feel of EMRs i.e. the interface design and form layouts of EMRs does not provide a sense to people that it is possible to organize their collaboration around it. This in turn hampers healthcare providers - who need to work with each other- from effectively collaborating. Together, their collaboration would have resolved the information needs, but the

4. FINDINGS From the data analysis, recurrent themes emerged, which on further constant comparative analysis converged onto four overarching barriers that hindered patient care teams‟ CIS. These were a) clash of "technological frames", b) lack of collective affordances, c) fear of deviations and d) alert fatigues. We elaborate upon these findings in this section.

4.1 Clash of Technological Frames We found that the “technological frames” that different patient care team members held on EMRs affected the way they used and appropriated EMRs, which in turn impacted their CIS. Orlikowski and Gash [15] refer to “technological frames” as the “subset of members' organizational frames that concern the assumptions, expectations, and knowledge they use to understand technology in organizations.” (p. 178). In other words, technological frames guide team members‟ perceptions and interpretations about a particular technology i.e. what that technology is, what it does and what it is used for. Technological frames also act as sensemaking devices for team members‟ to categorize a particular technology relative to other technologies, significantly shaping how the use, non-use and appropriation of that technology[15]. With respect to EMRs, members of the patient care teams perceived them in a multitude of ways. For instance, some of patient care team members, such as physicians, viewed EMRs as „information storage‟ tools, while others, such as nurses, viewed them as „information transfer‟ tools. These, in turn, contrasted with the frames held by the implementers and champions of EMRs, such as the CMIO, who viewed EMRs not just as

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We were able to fully record and transcribe one of the interviews. When we quote from that interview, we use the subscript “verbatim”. For quotes from other interviews, we use the subscript “from written notes”.

lack of collective affordances hindered their potential collaboration. In short, EMRs have affordances that could promote and facilitate only individual information seeking, but not collaborative information seeking. As EMRs are not able to facilitate CIS, providers resort to other modalities, such as phone calls, text messages and face-to-face interactions that could better augment their CIS activities.

These alert fatigues, although not affecting CIS activities in a direct way, does affect them in an indirect way. For instance, these alerts shape the patient care team members‟ emotional and affective responses towards the EMR system, which can induce variability in usage patterns. ..there is a lot of variability in the use of electronic records... And I think that this variability is due to either differences in knowledge, desire, or actual use… leading to the challenges of collaboration. (#CMIO, verbatim) As the variances in usage patterns increases, they pose challenges for collaboration as well as for collaborative information seeking. That is, if each of the members of the patient care team evoke different reactions to EMRs and use them in idiosyncratic ways, then there is a lack of common ground that is much needed for performing CIS.

4.3 Fear of Deviations Fear of deviations shaped the way patient care team members used and approached EMRs. These deviations could range anything from violating HIPAA compliance rules to breaching internal access control procedures. From the data analysis, we found that these deviations are often not intentional, but instead, accidental. For instance, consider the below vignette of a deviation incident that happened recently within the ED department – Physician P3 wanted to find out details of particular patients’ endoscopic results, but was not able to locate it in his usual folder. So, he logged into the EMR system which is located within the hospital organizations’ firewall, and invoked the internal email application to compose a mail to technician TK1 who was in-charge of providing the endoscopic results. He sent some patient identification information that would allow TK1 to locate the patient record. This was considered not as a deviation, since the entire communication happened through the internal email application that is shielded by secured firewall. However, TK1 had connected his internal email account with his Gmail account. Thus, all the incoming mails were automatically routed and forwarded to that Gmail account that is located on external servers. Thus, both physician P3 as well as technician TK1 was charged with deviating from access control procedures and from HIPAA compliance rules. From the above vignette, one could see that deviations emerged not in an intentional but in an accidental manner. As physician P3 reflected, Now, I’m very skeptical of using the system because it led me towards a deviation for which I’m not at all responsible...I think it would be useful to clearly specify and detail out the norms and standards for compliance (#physician p3, from written notes) These incidents of deviation, when shared across the hospital organization, imbue fear and skepticism on using the tool that led to the deviation. These impact the usage of EMRs, which in turn hamper CIS.

5. DISCUSSION In the last section, we described four barriers that could hinder patient care team members from using EMRs during their CIS activities. A closer investigation into these barriers suggests the need to understand the „technical‟ as well as the „social‟ aspects of EMRs into consideration. That is, if we want to improve the functionalities of EMRs for supporting CIS activities, we need to pay attention to both the social as well as the technical aspects surrounding the EMRs. In short, we need to take a socio-technical approach for the design and deployment of EMRs within healthcare organizations [17]. It is here that insights from the research field of Computer supported cooperative work (CSCW) might be useful. For instance, CSCW researchers have for long time investigated about collective design affordances that would facilitate collaborative information seeking. For instance, Morris and Horvitz[13] developed „SearchTogether‟, a publicly available browser plug-in that allows remote users to share search queries as well as search results with each other during collaborative tasks. Similarly, Amreshi and Morris[2] developed „CoSearch‟, a tool that is used for supporting group awareness using specialized browser with a “query queue” feature. Similar designs that could mimic the functionalities of the above tools, such as collaborative search features, query queues, could be incorporated into the existing EMR systems. These features could provide the collective affordances needed for promoting collaboration as well as for facilitating CIS. Similarly, split-screen functionalities could be incorporated into EMRs. These could enable members of the patient care teams to perform parallel division of labor, and collaboratively look for as well as integrate the information they find on a „real time‟ basis. These affordances that facilitate constant communication, division of labor, information sharing and integration of results could facilitate better CIS. As patient care delivery is now moving from individual-toindividual relationships to individual-to-health-system relationships, we are becoming increasingly reliant upon EMRs. In that sense, EMRs are not just tools for information storage, retrieval and transfer, but are platforms for orchestrating healthcare delivery. Differing perceptions on what EMR is will as we saw from the findings of our study - impact its subsequent usage. As the CMIO reflects below, That talks about the difficulty of using the electronic medical record for collaboration. Because different people have different perspectives on it. And really,

4.4 Alert Fatigue Participants expressed concerns over the increasing number of „alert‟ and „warning‟ messages shown by the EMR systems, which led to “alert fatigues”. As one nurse puts it, Warnings are too frequent.. there are too many alert messages, even for very trivial things that it becomes really distracting.. It distracts from the main task I’m doing at that time.. I might be looking at the patient or telling something to the resident, but these messages really distract me from doing them.. Sometimes, I couldn’t even respond quickly to the physician when he asks me for something because I was looking at those alert windows (#nurse N1, from written notes) 4

because the model of care we have in the United States now is really more towards health systems taking care of individuals, we rely much more on that record. And while some components of some vendors are very good for some provider types, they are not very good for others. (#CMIO, verbatim) Thereby, champions of EMRs should constantly communicate about the uniqueness of EMRs to different stakeholders. That is, they should make it clear that EMRs are not just electronic versions of paper records, but are platforms over which the whole patient-healthcare system relationship is enacted. Such communications would reduce the clash in the “technological frames” among different stakeholders, which would in turn enable them to develop common ground that is essential for successful CIS activities. Finally, the frequency of alerts and warning messages should be reduced by obtaining feedback from the patient care team members. Only critical alerts should be displayed as separate popup windows. Rest of them should either be not displayed at all, or be displayed non-intrusively at the „peripheral vision‟ area. These mechanisms– that take the ensemble of tools, technologies, people and processes into consideration - could potentially help minimize the barriers to using EMRs during CIS activities.

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6. CONCLUSION

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Although current EMRs have challenges that have yet to be overcome, they also have potentials to play a positive role in improving quality of medical care. From the research study, we identified a set of barriers to using EMRs during CIS activities. Understanding these barriers would bring us one step closer towards addressing challenges that are pertinent to the usage of EMRs within healthcare organizations. This study thus begins to lay the groundwork for more a detailed understanding about how patient care teams overcomes these challenges, and the mechanisms they use in the process. By identifying these processes and mechanisms, we can begin to design EMRs that could better support and augment CIS.

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Acknowledgments We thank the participants for their involvement in the study. We also thank Dr. Chris DeFlitch for his help and support. This research was funded in part by grant IIS 0844947 from the National Science Foundation. We also thank Penn State‟s Center for Integrated Healthcare Delivery Systems for partially funding this study.

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