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Is health information technology improving interprofessional care team communications? An ethnographic study in critical care
Journal of Interprofessional Education & Practice 10 (2018) 1e5
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com
Is health information technology improving interprofessional care team communications? An ethnographic study in critical care Myles Leslie a, b, *, Elise Paradis c, d a
Department of Community Health Sciences, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6 Canada School of Public Policy, University of Calgary, 5th Floor, 906 e 8 Avenue SW, Calgary, Alberta, T2P 1H9 Canada c Leslie Dan Faculty of Pharmacy & Department of Anesthesia, University of Toronto, 144 College Street, Toronto, Ontario, M5S 3M2 Canada d The Wilson Centre, 200 Elizabeth Street, 1ES-565, Toronto, Ontario, M5G 2C4 Canada b
a r t i c l e i n f o Article history: Received 1 February 2017 Received in revised form 6 October 2017 Accepted 13 October 2017 Keywords: Health information technology Interprofessional patient care team Ethnography Sociology
1. Introduction 1.1. Background The 2009 Affordable Care Act (ACA) encouraged the ‘meaningful use’ of Health Information Technology (HIT)1 to achieve improvements in healthcare.2e6 Specifically, the Office of the National Coordinator for Health Information Technology notes: “the main goals of HIT adoption are to achieve improved health and healthcare quality, safety, and communication among all members of the care team”.7 Computers in clinical spaces are thus intended to usher in a new and improved era of care team communication and interaction. Regardless of any changes to, or even the repeal of the ACA, HIT systems have become a pervasive presence in US healthcare, and are unlikely to be removed.8 Indeed, their presence in clinical settings at the behest of the federal government is the result of bi-partisan agreement over the course of more than a decade that electronic health records and the infrastructure to
* Corresponding author. Department of Community Health Sciences, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6 Canada. E-mail address: [email protected] (M. Leslie).
support them are central to modernizing the US system.9 This paper uses ethnographic methods to examine the front line communication experiences10 of care teams in two Intensive Care Units (ICUs) with high levels of HIT adoption. Ethnography is the systematic observation of people living and making sense of their lives in a specific cultural or organizational setting. Using ethnographic data, our paper illustrates how the new, policy-driven computer work on these units is being integrated into the value systems, social relationships, and communication patterns of these interprofessional teams. In this way it provides a view of how a policy is translated into action on the front lines of care,11 and how HIT influences the on-the-ground realities of interprofessionalism in a clinical context. Our observations and analysis of ICU nurses and physicians working with HIT are grounded in the idea that communications and interactions between clinicians “do not happen in a historical, social or technological vacuum.”12 As such, we approach HIT as part of a ‘sociotechnical ensemble,’13 viewing technical infrastructures and the clinicians who work with them as two sides of a single coin.14,15 HIT is on the one hand a suite of hardware, software, and networks. On the other, it is a site of social interaction where ICU professionals negotiate their communications and relationships with one another.
2. The study 2.1. Aims This paper focuses on understanding how ICU physicians and nurses experience and distribute HIT work. These experiences allow us to see how HIT is being incorporated into the professional worldviews and value systems of ICU clinicians.16e18 The paper describes new workloads intersecting with historical interprofessional relationships, and suggests that HIT work, as experienced and distributed by ICU care teams, may not reflect policy makers' intensions to improve communications.
https://doi.org/10.1016/j.xjep.2017.10.002 2405-4526/© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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M. Leslie, E. Paradis / Journal of Interprofessional Education & Practice 10 (2018) 1e5
2.2. Design
2.7. Rigour
The data we report here are a subset of a broader ethnographic study of interprofessional collaboration on four ICUs.19 The two locations discussed in this paper implemented the broadest range of HIT of the full sample, and are thus closer to using HIT as envisioned by policymakers. We observed HIT use and care team relationships on each unit simultaneously, giving the ICUs pseudonyms e Lakeside and Mid Valley e to protect their anonymity. The units deployed high-intensity ICU physician staffing, in which dedicated critical care specialists managed or co-managed patients.20 To improve comparability, we purposively recruited units that also matched on medical specialty and bed count. Our observations began with both authors acting as nonparticipant observers. These initial impressions were clarified first with informal and then formal interviews with staff. Informal interviews were conducted in natural breaks and pauses in the ICU workflow and sought to clarify the social meanings and motivations that informed clinicians' uses of HIT. Semi-structured formal interviews were recruited opportunistically, and digitally recorded and transcribed for analysis.
Both authors performed the coding, verifying one another's work and iterating the analysis in collaboration with the study's participants. Extracts from the coding are presented in the pages that follow to support our interpretation. The passages have been edited to ensure anonymity and clarity, with omissions or substitutions marked in square brackets. Each passage is attributed to a clinical role (e.g. Staff Nurse; Fellow Physician), with those roles expressing relative seniority within a profession.
2.3. Participants
3.2. Nurses and the ancillary nature of computer work
Over the course of the ethnography 287 unique ICU clinical care team members were identified in our fieldnotes at the Lakeside and Mid Valley sites. Lakeside and Mid Valley had extensive HIT systems in place. Lakeside's 12 patient beds were supplemented with 29 fixed computer workstations and 5 mobile workstations. Of these 11 were dedicated to the use of nurses, 10 to the use of doctors, and 13 were administrative, or at the bedside. Mid Valley's 12 beds were supplemented with 32 fixed, and 6 mobile workstations. Of these 12 were dedicated to the use of nurses, 11 to the use of doctors, and 15 were administrative, or at the bedside. Both ICUs ran a broad range of HIT applications on this hardware, using distinct software applications to enter and manage: nursing notes, medical notes, medication prescribing and dispensing, diagnostic results, and intra-hospital communications.
Nurses experienced HIT work as a documentary or accountability-oriented layer of activity that overlaid the work at the heart of their ‘real’ professional role.
2.4. Data collection We kept detailed field notes, recording observations and conversations within minutes of their occurrence, and then writing these up in more detail for future analysis. From December 2012 to December 2013, 369 h of observations were carried out on the two units. 2.5. Ethical considerations Institutional review boards at both of the hospitals approved the study protocol for this research. Following best practices in the conduct of healthcare ethnography,21 all interviews included checks on emerging interpretations of how HIT work was experienced and distributed. In this way the social meanings of HIT work in the ICU presented here emerged from conversations among researchers and with research participants, who had the opportunity to refute or refine emerging interpretations. 2.6. Data analysis We carried out data analysis using the constant comparative method,22,23 with initial themes identified, re-visited, expanded, collapsed and compared across units. Topic identification and coding were facilitated by NVIVO10 software.
3. Findings 3.1. The experience of HIT Participants' experiences of HIT varied according to their professional background, with distinct patterns of HIT integration emerging for nurses and physicians. Nurses tended to see HIT work as ancillary to their ‘real’ or core professional work, while physicians tended to see HIT work as central to their professional activities.
Save all that money [spent on IT and] give us an extra nurse … and guess what? People will get better care. …. My favorite thing, and I've told you this before, was the homeless people. I liked it when a homeless person came in. [I could] go in; wash [and] shave them; make them feel like a human being again. Transform them into what they used to be, probably. Do you think people have time to do that now? No. (Lakeside, Staff RN) Many nurses, and older nurses in particular, contrasted ‘the work’ e the reason they had become nurses in the first place e with ‘the paperwork’ which, with the implementation of HIT, had become computerized. HIT was seen as a substitute platform for previously analog documentary and administrative work, and thus as ancillary rather than central to the ‘real’ work of nursing: handson patient care. While there was grumbling at the time required to “tend to the computer,” nurses generally accepted this high volume. Beyond the fact that their employer required them to use HIT, their acceptance hinged in part on their sense that the computers in their work environment were a force for improving care quality. A junior Staff Nurse at Mid Valley noted that the unit's online charting system made it more likely for nurses “to get their vital [signs] in every hour, and more likely to get their assessments done every four hours.” The pick-lists, forms, and time stamps of the HIT systems made it both easier to enter information, and more obvious when information had not been entered. Similarly, another Mid Valley Staff Nurse was “reminded, by looking at [her computer] screen, of several items that slipped her mind amongst all the other work she had been doing since her patient's [emergency] admission.” A senior Staff Nurse at Lakeside described how he hoped that documenting his work on the HIT system would facilitate broader safety and quality improvement efforts: If [the hospital] can take [this ICU's] information and shoot it right to [an off-site quality improvement team] for the things that they need to know, that's wonderful.
M. Leslie, E. Paradis / Journal of Interprofessional Education & Practice 10 (2018) 1e5
In addition to structuring routine patient monitoring, as well as jogging nurses' memories and supplying data to external improvement efforts, HIT systems were seen as offering a mix of care coordination and legal benefits. Junior nurses repeated variations of the phrase “If it isn't documented, it wasn't done” to explain these benefits. They saw their charting system as both facilitating care (maintaining a record for colleagues to ensure continuity) and as an accountability mechanism should a complaint be lodged or an incident occur. Thus, nurses' acceptance of HIT, despite being ancillary to their core work as professionals, hinged on narratives that emphasized care quality benefits for patients and legal benefits for themselves.
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says [the Resident MD] gesturing at her computer. “[My job is] sitting in front of a computer, talking to other doctors to get their take on things. Earlier on in your training you are focused on getting [the patient's] story. But as you progress you learn how to do something about the history you've taken and it becomes more about management.” (Lakeside, Resident MD) Unlike ICU nurses who found HIT work to be ancillary to their core care delivery mission, the physicians at Lakeside and Mid Valley experienced computer work as central to their role as diagnosticians and patient care managers. 3.4. The distribution of HIT
3.3. Physicians and the central nature of computer work Unlike ICU nurses, physicians and their assistants saw HIT as central to their work and professional identities. A physician's assistant described how HIT was tightly integrated into medical practice on the ICU. “Being able to track vital signs, concurrently [with] lab values, concurrently [with] medications administered, and correlating all that data together is extremely important …. without the IT … we would not be able to do what we do. It's imperative to be able to see all that data: see flows, see trends, graph things out. (Lakeside, Physician's Assistant) This sense that the core work of delivering critical care requires advanced data handling and processing capacities was widely shared among physicians. A senior physician described not just the centrality of HIT to his work, but how electronic data streams (or ‘iPatients,’24,25) had come to replace the physical bodies of the patients under his care: “Well, this [points to computer screen] is more and more the patient. I mean, in many respects it really is. We certainly spend the bulk of our time in front of a screen.” (Mid Valley, Attending MD) This description of the centrality of computer work was borne out in both our observations, and interviews with other ICU staff. A senior nurse on Lakeside described how computers replace physical bodies in the minds of younger doctors: I overheard an intern and a resident talking to another one about [our ICU medical director], and [the intern] said, “[The patient] in room five is really sick! And man, [the medical director] went in there [and did] an old-school assessment!” I'm thinking “‘Is there a ‘new school’?...What's new school? Is it like,‘no assessment’? You look at what's in the computer?” (Lakeside, Charge RN) The attending physician and charge nurse's comments suggest a shift not just in the work, but in the values at the heart of an ICU physician's professional role: rather than experiencing HIT and its workload as a limit on their professional autonomy, as has been found in other contexts26 physicians have integrated computers into what it means to be a ‘good doctor’. With the iPatient at the center of ICU care delivery, the junior doctors in our study had adjusted their definition of what constitutes legitimate and valorous medical work: “[Talking with patients] is a luxury … that you have when you're a medical student. … But for now, this is me, managing my patients,”
3.4.1. Volumes of work For nurses and physicians on both units HIT work replaced traditional charting or note writing. For nurses particularly this was not merely a substitution of digital for analog work, but also an introduction of time-consuming and cognitively-demanding labor. With different care team members using different software to contribute different documents to a patient's electronic record, nurses found themselves spending significant time spotting and filling gaps across software applications. A staff nurse's explanation of this ‘extra’ work highlights the time and thought required to reconcile and coordinate the data streams: “[The patient is] much sicker [now] but the [medical] orders still haven't changed. 6 hours later. It looks like there's even more orders,” says the Staff Nurse as she scans down the screen. “Which of these is real … and which are just hanging around the system?” she asks rhetorically. Pointing to a number on the screen, she adds: “See here? That's way too low to match [the patient's] change in status.” (Lakeside) “Like [for this patient's] nutrition: [The medical notes] say he's being fed through an NG tube, but if I check his [nursing] flowsheet …” The Staff Nurse toggles back to the nursing chart from the medical notes. “See?” she asks “He hasn't had anything put down the tube in days. I'll switch his [record]. ” (Lakeside) These efforts to align the data streams of various HIT applications with one another, and with the fast-changing physical and social conditions of the patient, were constant, required significant amounts of time, and deep concentration. They also fell disproportionately to nurses. Generally, physicians e both junior and senior e held a privileged position when it came to aligning and reconciling patients' data across applications. They worked exclusively in the medical notation and prescribing systems and did not access the nursing notation system, or drug dispensing system which significantly reduced their exposure to misaligned data. Additionally, the physicians' views of the prescription software screens were ‘cleaner’ than those of the nurses, as expired or discontinued orders were erased from their screens but not from nurses'. Junior physicians could encounter some of the alignment and reconciliation demands that were constant for nurses: “Here's a note where it says [the patient] is missing a foot. ‘Previous foot amputation in his teens,’ it says here. Well, I just checked and he must have magic regenerative power because it's grown back! (Mid Valley, Resident MD) Beyond catching and remediating these sorts of medical charting errors, some junior doctors proactively worked to align data
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across two of the four software applications used on the ICUs. Others were less diligent or had less time. As one Lakeside nurse noted, “Some [junior doctors] are really good about keeping the orders matched up to the [medical] notes. But sometimes it's something you want to check.” This variability in practice forced nurses to be constantly attuned to discrepancies and misaligned data across not just nursing applications, but physicians' systems as well. 3.4.2. Spaces of work The physical distribution of HIT work e the spaces in which it was conducted e tended to reflect traditional relationships between nurses and physicians. Physicians and Physician Assistants conducted their central, alignment-light computer work in a single co-located space at both Lakeview and Mid Valley. In contrast, nurses conducted their ancillary, alignment-heavy computer work in a range of geographically separate locations such as the nursing station and bedside computers. This electronic siloing along professional lines could be seen by both nurses and physicians as detracting from care team communications. “Back in the day, the doctors wrote an order on the bedside chart. … And that would give me what I call ‘face time’ with that physician. [Time where] there's give and take. Today, they put that order in the computer. It comes up on my screen. It goes to pharmacy … It goes everywhere. And … there's never face time unless I run back to them and say [something] and I don't always have the opportunity to run back because I'm tending to the computer. (Lakeside, Charge RN) “What's unfortunate about the computers is that they bought them to help with an aging, sicker population, right? We've got to do this to make things more efficient with all the extra load, but … to be honest, I feel a lot better when I go to the nurse and check in to make sure the order's properly understood. But that's the old way. The way we're supposed to be replacing, right?” (Lakeside, Physician's Assistant) In this way, it was not only the volume of HIT work that was divvied up unevenly between the two professions: the physical distribution of HIT work reinforced traditional divisions between the professions as it built communication siloes. 4. Discussion While HIT work affected the lives of both nurses and physicians, the experience and distribution of this new, policy-imposed work was different and unequal across the two groups. Echoing findings that nurses often need to “accommodate technologies that hinder rather than support their activities”,27 nurses saw HIT work as ancillary to their professional mission of care delivery. In contrast, physicians saw the management of digital data streams as central e perhaps even more central than flesh-and-blood patients themselves e to their professional activities. These divergent experiences and narratives of how HIT work fits into the ICU world were accompanied by an unequal distribution of computer work between the two groups. A distribution that did not match the perceived centrality of the work. Simply put, HIT implementation created more work for nurses than it did for doctors. Much of the HIT work performed by nurses was invisible,28 with the complexities and cognitive demands of aligning and picking through data across multiple systems underestimated and undervalued, echoing
other common nursing practices in the ICU.27,29 While physicians had the option e but not the obligation e to perform data alignment work, nurses had to accommodate any less-than-diligent behavior on the part of physicians. Similarly, nurses' displays forced them to pick through expired and discontinued prescriptions that doctors did not see and were not required to clean up. Our data underscore the inequalities that can be created or maintained when non-physicians must devote time and effort to finding and remediating the computer data entry faults of physicians.30 In this way, traditional hierarchies were built into and reinforced by HIT systems. The experience and distribution of HIT work re-inscribed a professional hierarchy in which physicians enjoyed a privileged, super-ordinate position, and nurses acquired a new form of cognitively demanding work31,32 without additional compensation or recognition. Although a central intention of policy makers was to improve care team communications through HIT use, Lakeside and Mid Valley's implementations did not meet these expectations. Care delivery was siloed rather than coordinated and consequently planted doubts in a range of clinicians' minds about HIT's capacity to support the communication necessary for safe, high-quality care.33 5. Limitations Traditionally, ethnographers have aimed to provide rich descriptions of the customs, roles, activities and beliefs of the people they observe, embedding them within their broader environment and history.34,35 Accomplishing this for two hospitals with data collected over more than a year's time by two similarly trained ethnographers with nonetheless widely different perspectives, would have required a much longer manuscript. As such, the article we present here should be seen as part of an emerging tradition that focuses on improving the quality and safety of care21 and so a snapshot highlighting similarities and differences across study sites in answer to a specific question: How are ICU clinicians' experiences of HIT shaping the communications that support safe, high quality interprofessional care? Future research will need to inquire into whether the intuitions of our participants, and others, about the importance of face-to-face interactions are borne out as factors in patient outcomes such as length of stay, infection rates, errors rates, and mortality. While we have touched on the differences between more and less senior nurses as they made sense of HIT work and integrated it into their professional lives, our methods and analysis are not geared to deal with the potentially confounding role played by remembering, or never having known, a paper-based world prior to HIT. Our data set and so our analysis are unable to tease out broader trends in how junior and senior e digital native and digital immigrant e members of the interprofessional team may be differentially deploying cultural narratives to explain and justify the policy driven technical elements of their work world. Further research is needed to conduct this sort of analysis. While ethnographic findings can be dismissed as too anchored in their specific contexts to be generalizable to other sites, the dynamics we observed following the scientific precepts of the method were more similar than different across the ICUs we reported on here, and were confirmed by two different ethnographers. This, combined with the degree of concordance between our findings and others' regarding the way HIT can disrupt communications,33 as well as the extent, cognitive load, and unequal distribution of HIT work,30e32,36 suggests that our findings may well
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extend beyond the ICUs in our study. 6. Conclusion In the ICU environment, achieving policy goals of care team communication improvement via HIT systems requires attention both to clinicians' experiences of the new work, and how that work is distributed among ICU professionals. Particular attention is required to avoid returning to interprofessional relationships that privilege physicians at the expense of nurses, and build siloes rather than lines of communication. Funding This work was supported by the Gordon and Betty Moore Foundation. Acknowledgements The authors wish to thank Hanan Aboumatar, Simon Kitto, Peter Pronovost, and Scott Reeves for their assistance in the data collection phase of this research. References 1. US Department of Health and Human Services Hg. Certification and EHR Incentives: HITECH Act. http://www.healthit.gov/policy-researchersimplementers/hitech-act-0. Accessed January 20, 2014. 2. Blumenthal D. Launching HITECH. N. Engl J Med. 2010;362(5):382e385. 3. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N. Engl J Med. 2010;363(6):501e504. 4. Buntin MB, Jain SH, Blumenthal D. Health information technology: laying the infrastructure for national health reform. Health Aff. 2010;29(6):1214e1219. 5. Kaushal R, Blumenthal D. Introduction and commentary for special issue on health information technology. Health Serv Res. 2014;49(1 Pt 2):319e324. 6. Mechanic D. Rethinking medical professionalism: the role of information technology and practice innovations. Milbank Q. 2008;86(2):327e358. 7. Technology OotNCfHI. In: Services HaH, ed. Health it Enabled Quality Improvement: A Vision to Achieve Better Health and Health Care. 2014. Washington, DC. 8. Electronic Health Records: The New Lightning Rod in Health Care [computer Program]. The Commonwealth Fund; 2014. 9. Wachter RM. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age. New York, NY: McGraw Hill Education; 2015. 10. Mitchell G, Porter S, Manias E. A critical ethnography of communication processes involving the management of oral chemotherapeutic agents by patients with a primary diagnosis of colorectal cancer: study protocol. J Adv Nurs. 2015;71(4):922e932. 11. Rankin JM. The rhetoric of patient and family centred care: an institutional ethnography into what actually happens. J Adv Nurs. 2015;71(3):526e534. 12. Paradis E, Leslie M, Puntillo K, et al. Delivering interprofessional care in intensive care: a scoping review of ethnographic studies. Am J Crit Care. 2014;23(3):230e238. 13. Bijker WE. Of Bicycles, Bakelites, and Bulbs: Toward a Theory of Sociotechnical Change. Cambridge, Mass. ; London: MIT Press; 1995. 14. Bijker WE, Law J. Shaping Technology/building Society : Studies in Sociotechnical
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Change. Cambridge, Mass. ; London: MIT Press; 1992. 15. MacKenzie DA, Wajcman J. The Social Shaping of Technology. second ed. Buckingham: Open University Press; 1999. 16. Star SL. The politics of formal representations: wizards, gurus and organizational complexity. In: Star SL, ed. Ecologies of Knowledge : Work and Politics in Science and Technology. Albany: State University of New York Press; 1995. 17. Kaplan B. The computer prescription: medical computing, public policy, and views of history. Sci Technol Hum Values. 1995;20(1):5e38. 18. Niezen MGH, Bal R, Ad Bont. Reconfiguring policy and clinical practice: how databases have transformed the regulation of pharmaceutical care? Sci Technol Hum Values. 2013;38(1):44e66. 19. Paradis E, Reeves S, Leslie M, et al. Exploring the nature of interprofessional collaboration and family member involvement in an intensive care context. J Interprof Care. 2013;28(1):74e75. https://doi.org/10.3109/ 13561820.2013.781141. 20. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. J Am Med Assoc. 2002;288(17):2151e2162. 21. Leslie M, Paradis E, Gropper MA, Reeves S, Kitto S. Applying ethnography to the study of context in healthcare quality and safety. Br Med J Qual Saf. 2013;23(2): 99e105. 22. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. New York: Aldine de Gruyter; 1968. 23. Boeije H. A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Qual Quantity. 2002;36(4):391e409. 24. Verghese A. Culture shock d patient as icon, icon as patient. N. Engl J Med. 2008;359(26):2748e2751. 25. Wachter RM. Chapter 3: The IPatient. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age. New York, NY: McGraw Hill Education; 2015:23e28. 26. Johnson DR. Technological change and professional control in the professoriate. Sci Technol Hum Values. 2013;38(1):126e149. 27. Allen D. Re-conceptualising holism in the contemporary nursing mandate: from individual to organisational relationships. Soc Sci Med. 2014;119: 131e138. 28. Mort M, May CR, Williams T. Remote doctors and absent patients: acting at a distance in telemedicine? Sci Technol Hum Values. 2003;28(2):274e295. 29. Dale CM, Angus JE, Sinuff T, Rose L. Ethnographic investigation of oral care in the intensive care unit. Am J Crit Care. 2016;25(3):249e256. 30. Georgiou A, Westbrook J, Braithwaite J, et al. When requests become ordersda formative investigation into the impact of a computerized physician order entry system on a pathology laboratory service. Int J Med Inf. 2007;76(8): 583e591. 31. Westbrook JI, Baysari MT, Li L, Burke R, Richardson KL, Day RO. The safety of electronic prescribing: manifestations, mechanisms, and rates of systemrelated errors associated with two commercial systems in hospitals. J Am Med Inf Assoc. 2013;20(6):1159e1167. 32. Westbrook JI, Li L, Georgiou A, Paoloni R, Cullen J. Impact of an electronic medication management system on hospital doctors' and nurses' work: a controlled preepost, time and motion study. J Am Med Inf Assoc. 2013;20(6): 1150e1158. 33. Taylor SP, Ledford R, Palmer V, Abel E. We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication. BMJ Qual Saf. 2014;23(7):584e588. 34. O'Reilly K. Ethnographic Methods. second ed. London ; New York: Routledge; 2012. 35. Paradis E, Leslie M, Gropper M. Interprofessional rhetoric and operational realities: a study of morning rounds in four intensive care units. Adv Health Sci Educ. 2016;21(4):735e748. 36. Mort M, Finch T, May C. Making and unmaking telepatients: identity and governance in new health technologies. Sci Technol Hum Values. 2009;34(1): 9e33.
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com
Is health information technology improving interprofessional care team communications? An ethnographic study in critical care Myles Leslie a, b, *, Elise Paradis c, d a
Department of Community Health Sciences, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6 Canada School of Public Policy, University of Calgary, 5th Floor, 906 e 8 Avenue SW, Calgary, Alberta, T2P 1H9 Canada c Leslie Dan Faculty of Pharmacy & Department of Anesthesia, University of Toronto, 144 College Street, Toronto, Ontario, M5S 3M2 Canada d The Wilson Centre, 200 Elizabeth Street, 1ES-565, Toronto, Ontario, M5G 2C4 Canada b
a r t i c l e i n f o Article history: Received 1 February 2017 Received in revised form 6 October 2017 Accepted 13 October 2017 Keywords: Health information technology Interprofessional patient care team Ethnography Sociology
1. Introduction 1.1. Background The 2009 Affordable Care Act (ACA) encouraged the ‘meaningful use’ of Health Information Technology (HIT)1 to achieve improvements in healthcare.2e6 Specifically, the Office of the National Coordinator for Health Information Technology notes: “the main goals of HIT adoption are to achieve improved health and healthcare quality, safety, and communication among all members of the care team”.7 Computers in clinical spaces are thus intended to usher in a new and improved era of care team communication and interaction. Regardless of any changes to, or even the repeal of the ACA, HIT systems have become a pervasive presence in US healthcare, and are unlikely to be removed.8 Indeed, their presence in clinical settings at the behest of the federal government is the result of bi-partisan agreement over the course of more than a decade that electronic health records and the infrastructure to
* Corresponding author. Department of Community Health Sciences, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6 Canada. E-mail address: [email protected] (M. Leslie).
support them are central to modernizing the US system.9 This paper uses ethnographic methods to examine the front line communication experiences10 of care teams in two Intensive Care Units (ICUs) with high levels of HIT adoption. Ethnography is the systematic observation of people living and making sense of their lives in a specific cultural or organizational setting. Using ethnographic data, our paper illustrates how the new, policy-driven computer work on these units is being integrated into the value systems, social relationships, and communication patterns of these interprofessional teams. In this way it provides a view of how a policy is translated into action on the front lines of care,11 and how HIT influences the on-the-ground realities of interprofessionalism in a clinical context. Our observations and analysis of ICU nurses and physicians working with HIT are grounded in the idea that communications and interactions between clinicians “do not happen in a historical, social or technological vacuum.”12 As such, we approach HIT as part of a ‘sociotechnical ensemble,’13 viewing technical infrastructures and the clinicians who work with them as two sides of a single coin.14,15 HIT is on the one hand a suite of hardware, software, and networks. On the other, it is a site of social interaction where ICU professionals negotiate their communications and relationships with one another.
2. The study 2.1. Aims This paper focuses on understanding how ICU physicians and nurses experience and distribute HIT work. These experiences allow us to see how HIT is being incorporated into the professional worldviews and value systems of ICU clinicians.16e18 The paper describes new workloads intersecting with historical interprofessional relationships, and suggests that HIT work, as experienced and distributed by ICU care teams, may not reflect policy makers' intensions to improve communications.
https://doi.org/10.1016/j.xjep.2017.10.002 2405-4526/© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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M. Leslie, E. Paradis / Journal of Interprofessional Education & Practice 10 (2018) 1e5
2.2. Design
2.7. Rigour
The data we report here are a subset of a broader ethnographic study of interprofessional collaboration on four ICUs.19 The two locations discussed in this paper implemented the broadest range of HIT of the full sample, and are thus closer to using HIT as envisioned by policymakers. We observed HIT use and care team relationships on each unit simultaneously, giving the ICUs pseudonyms e Lakeside and Mid Valley e to protect their anonymity. The units deployed high-intensity ICU physician staffing, in which dedicated critical care specialists managed or co-managed patients.20 To improve comparability, we purposively recruited units that also matched on medical specialty and bed count. Our observations began with both authors acting as nonparticipant observers. These initial impressions were clarified first with informal and then formal interviews with staff. Informal interviews were conducted in natural breaks and pauses in the ICU workflow and sought to clarify the social meanings and motivations that informed clinicians' uses of HIT. Semi-structured formal interviews were recruited opportunistically, and digitally recorded and transcribed for analysis.
Both authors performed the coding, verifying one another's work and iterating the analysis in collaboration with the study's participants. Extracts from the coding are presented in the pages that follow to support our interpretation. The passages have been edited to ensure anonymity and clarity, with omissions or substitutions marked in square brackets. Each passage is attributed to a clinical role (e.g. Staff Nurse; Fellow Physician), with those roles expressing relative seniority within a profession.
2.3. Participants
3.2. Nurses and the ancillary nature of computer work
Over the course of the ethnography 287 unique ICU clinical care team members were identified in our fieldnotes at the Lakeside and Mid Valley sites. Lakeside and Mid Valley had extensive HIT systems in place. Lakeside's 12 patient beds were supplemented with 29 fixed computer workstations and 5 mobile workstations. Of these 11 were dedicated to the use of nurses, 10 to the use of doctors, and 13 were administrative, or at the bedside. Mid Valley's 12 beds were supplemented with 32 fixed, and 6 mobile workstations. Of these 12 were dedicated to the use of nurses, 11 to the use of doctors, and 15 were administrative, or at the bedside. Both ICUs ran a broad range of HIT applications on this hardware, using distinct software applications to enter and manage: nursing notes, medical notes, medication prescribing and dispensing, diagnostic results, and intra-hospital communications.
Nurses experienced HIT work as a documentary or accountability-oriented layer of activity that overlaid the work at the heart of their ‘real’ professional role.
2.4. Data collection We kept detailed field notes, recording observations and conversations within minutes of their occurrence, and then writing these up in more detail for future analysis. From December 2012 to December 2013, 369 h of observations were carried out on the two units. 2.5. Ethical considerations Institutional review boards at both of the hospitals approved the study protocol for this research. Following best practices in the conduct of healthcare ethnography,21 all interviews included checks on emerging interpretations of how HIT work was experienced and distributed. In this way the social meanings of HIT work in the ICU presented here emerged from conversations among researchers and with research participants, who had the opportunity to refute or refine emerging interpretations. 2.6. Data analysis We carried out data analysis using the constant comparative method,22,23 with initial themes identified, re-visited, expanded, collapsed and compared across units. Topic identification and coding were facilitated by NVIVO10 software.
3. Findings 3.1. The experience of HIT Participants' experiences of HIT varied according to their professional background, with distinct patterns of HIT integration emerging for nurses and physicians. Nurses tended to see HIT work as ancillary to their ‘real’ or core professional work, while physicians tended to see HIT work as central to their professional activities.
Save all that money [spent on IT and] give us an extra nurse … and guess what? People will get better care. …. My favorite thing, and I've told you this before, was the homeless people. I liked it when a homeless person came in. [I could] go in; wash [and] shave them; make them feel like a human being again. Transform them into what they used to be, probably. Do you think people have time to do that now? No. (Lakeside, Staff RN) Many nurses, and older nurses in particular, contrasted ‘the work’ e the reason they had become nurses in the first place e with ‘the paperwork’ which, with the implementation of HIT, had become computerized. HIT was seen as a substitute platform for previously analog documentary and administrative work, and thus as ancillary rather than central to the ‘real’ work of nursing: handson patient care. While there was grumbling at the time required to “tend to the computer,” nurses generally accepted this high volume. Beyond the fact that their employer required them to use HIT, their acceptance hinged in part on their sense that the computers in their work environment were a force for improving care quality. A junior Staff Nurse at Mid Valley noted that the unit's online charting system made it more likely for nurses “to get their vital [signs] in every hour, and more likely to get their assessments done every four hours.” The pick-lists, forms, and time stamps of the HIT systems made it both easier to enter information, and more obvious when information had not been entered. Similarly, another Mid Valley Staff Nurse was “reminded, by looking at [her computer] screen, of several items that slipped her mind amongst all the other work she had been doing since her patient's [emergency] admission.” A senior Staff Nurse at Lakeside described how he hoped that documenting his work on the HIT system would facilitate broader safety and quality improvement efforts: If [the hospital] can take [this ICU's] information and shoot it right to [an off-site quality improvement team] for the things that they need to know, that's wonderful.
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In addition to structuring routine patient monitoring, as well as jogging nurses' memories and supplying data to external improvement efforts, HIT systems were seen as offering a mix of care coordination and legal benefits. Junior nurses repeated variations of the phrase “If it isn't documented, it wasn't done” to explain these benefits. They saw their charting system as both facilitating care (maintaining a record for colleagues to ensure continuity) and as an accountability mechanism should a complaint be lodged or an incident occur. Thus, nurses' acceptance of HIT, despite being ancillary to their core work as professionals, hinged on narratives that emphasized care quality benefits for patients and legal benefits for themselves.
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says [the Resident MD] gesturing at her computer. “[My job is] sitting in front of a computer, talking to other doctors to get their take on things. Earlier on in your training you are focused on getting [the patient's] story. But as you progress you learn how to do something about the history you've taken and it becomes more about management.” (Lakeside, Resident MD) Unlike ICU nurses who found HIT work to be ancillary to their core care delivery mission, the physicians at Lakeside and Mid Valley experienced computer work as central to their role as diagnosticians and patient care managers. 3.4. The distribution of HIT
3.3. Physicians and the central nature of computer work Unlike ICU nurses, physicians and their assistants saw HIT as central to their work and professional identities. A physician's assistant described how HIT was tightly integrated into medical practice on the ICU. “Being able to track vital signs, concurrently [with] lab values, concurrently [with] medications administered, and correlating all that data together is extremely important …. without the IT … we would not be able to do what we do. It's imperative to be able to see all that data: see flows, see trends, graph things out. (Lakeside, Physician's Assistant) This sense that the core work of delivering critical care requires advanced data handling and processing capacities was widely shared among physicians. A senior physician described not just the centrality of HIT to his work, but how electronic data streams (or ‘iPatients,’24,25) had come to replace the physical bodies of the patients under his care: “Well, this [points to computer screen] is more and more the patient. I mean, in many respects it really is. We certainly spend the bulk of our time in front of a screen.” (Mid Valley, Attending MD) This description of the centrality of computer work was borne out in both our observations, and interviews with other ICU staff. A senior nurse on Lakeside described how computers replace physical bodies in the minds of younger doctors: I overheard an intern and a resident talking to another one about [our ICU medical director], and [the intern] said, “[The patient] in room five is really sick! And man, [the medical director] went in there [and did] an old-school assessment!” I'm thinking “‘Is there a ‘new school’?...What's new school? Is it like,‘no assessment’? You look at what's in the computer?” (Lakeside, Charge RN) The attending physician and charge nurse's comments suggest a shift not just in the work, but in the values at the heart of an ICU physician's professional role: rather than experiencing HIT and its workload as a limit on their professional autonomy, as has been found in other contexts26 physicians have integrated computers into what it means to be a ‘good doctor’. With the iPatient at the center of ICU care delivery, the junior doctors in our study had adjusted their definition of what constitutes legitimate and valorous medical work: “[Talking with patients] is a luxury … that you have when you're a medical student. … But for now, this is me, managing my patients,”
3.4.1. Volumes of work For nurses and physicians on both units HIT work replaced traditional charting or note writing. For nurses particularly this was not merely a substitution of digital for analog work, but also an introduction of time-consuming and cognitively-demanding labor. With different care team members using different software to contribute different documents to a patient's electronic record, nurses found themselves spending significant time spotting and filling gaps across software applications. A staff nurse's explanation of this ‘extra’ work highlights the time and thought required to reconcile and coordinate the data streams: “[The patient is] much sicker [now] but the [medical] orders still haven't changed. 6 hours later. It looks like there's even more orders,” says the Staff Nurse as she scans down the screen. “Which of these is real … and which are just hanging around the system?” she asks rhetorically. Pointing to a number on the screen, she adds: “See here? That's way too low to match [the patient's] change in status.” (Lakeside) “Like [for this patient's] nutrition: [The medical notes] say he's being fed through an NG tube, but if I check his [nursing] flowsheet …” The Staff Nurse toggles back to the nursing chart from the medical notes. “See?” she asks “He hasn't had anything put down the tube in days. I'll switch his [record]. ” (Lakeside) These efforts to align the data streams of various HIT applications with one another, and with the fast-changing physical and social conditions of the patient, were constant, required significant amounts of time, and deep concentration. They also fell disproportionately to nurses. Generally, physicians e both junior and senior e held a privileged position when it came to aligning and reconciling patients' data across applications. They worked exclusively in the medical notation and prescribing systems and did not access the nursing notation system, or drug dispensing system which significantly reduced their exposure to misaligned data. Additionally, the physicians' views of the prescription software screens were ‘cleaner’ than those of the nurses, as expired or discontinued orders were erased from their screens but not from nurses'. Junior physicians could encounter some of the alignment and reconciliation demands that were constant for nurses: “Here's a note where it says [the patient] is missing a foot. ‘Previous foot amputation in his teens,’ it says here. Well, I just checked and he must have magic regenerative power because it's grown back! (Mid Valley, Resident MD) Beyond catching and remediating these sorts of medical charting errors, some junior doctors proactively worked to align data
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across two of the four software applications used on the ICUs. Others were less diligent or had less time. As one Lakeside nurse noted, “Some [junior doctors] are really good about keeping the orders matched up to the [medical] notes. But sometimes it's something you want to check.” This variability in practice forced nurses to be constantly attuned to discrepancies and misaligned data across not just nursing applications, but physicians' systems as well. 3.4.2. Spaces of work The physical distribution of HIT work e the spaces in which it was conducted e tended to reflect traditional relationships between nurses and physicians. Physicians and Physician Assistants conducted their central, alignment-light computer work in a single co-located space at both Lakeview and Mid Valley. In contrast, nurses conducted their ancillary, alignment-heavy computer work in a range of geographically separate locations such as the nursing station and bedside computers. This electronic siloing along professional lines could be seen by both nurses and physicians as detracting from care team communications. “Back in the day, the doctors wrote an order on the bedside chart. … And that would give me what I call ‘face time’ with that physician. [Time where] there's give and take. Today, they put that order in the computer. It comes up on my screen. It goes to pharmacy … It goes everywhere. And … there's never face time unless I run back to them and say [something] and I don't always have the opportunity to run back because I'm tending to the computer. (Lakeside, Charge RN) “What's unfortunate about the computers is that they bought them to help with an aging, sicker population, right? We've got to do this to make things more efficient with all the extra load, but … to be honest, I feel a lot better when I go to the nurse and check in to make sure the order's properly understood. But that's the old way. The way we're supposed to be replacing, right?” (Lakeside, Physician's Assistant) In this way, it was not only the volume of HIT work that was divvied up unevenly between the two professions: the physical distribution of HIT work reinforced traditional divisions between the professions as it built communication siloes. 4. Discussion While HIT work affected the lives of both nurses and physicians, the experience and distribution of this new, policy-imposed work was different and unequal across the two groups. Echoing findings that nurses often need to “accommodate technologies that hinder rather than support their activities”,27 nurses saw HIT work as ancillary to their professional mission of care delivery. In contrast, physicians saw the management of digital data streams as central e perhaps even more central than flesh-and-blood patients themselves e to their professional activities. These divergent experiences and narratives of how HIT work fits into the ICU world were accompanied by an unequal distribution of computer work between the two groups. A distribution that did not match the perceived centrality of the work. Simply put, HIT implementation created more work for nurses than it did for doctors. Much of the HIT work performed by nurses was invisible,28 with the complexities and cognitive demands of aligning and picking through data across multiple systems underestimated and undervalued, echoing
other common nursing practices in the ICU.27,29 While physicians had the option e but not the obligation e to perform data alignment work, nurses had to accommodate any less-than-diligent behavior on the part of physicians. Similarly, nurses' displays forced them to pick through expired and discontinued prescriptions that doctors did not see and were not required to clean up. Our data underscore the inequalities that can be created or maintained when non-physicians must devote time and effort to finding and remediating the computer data entry faults of physicians.30 In this way, traditional hierarchies were built into and reinforced by HIT systems. The experience and distribution of HIT work re-inscribed a professional hierarchy in which physicians enjoyed a privileged, super-ordinate position, and nurses acquired a new form of cognitively demanding work31,32 without additional compensation or recognition. Although a central intention of policy makers was to improve care team communications through HIT use, Lakeside and Mid Valley's implementations did not meet these expectations. Care delivery was siloed rather than coordinated and consequently planted doubts in a range of clinicians' minds about HIT's capacity to support the communication necessary for safe, high-quality care.33 5. Limitations Traditionally, ethnographers have aimed to provide rich descriptions of the customs, roles, activities and beliefs of the people they observe, embedding them within their broader environment and history.34,35 Accomplishing this for two hospitals with data collected over more than a year's time by two similarly trained ethnographers with nonetheless widely different perspectives, would have required a much longer manuscript. As such, the article we present here should be seen as part of an emerging tradition that focuses on improving the quality and safety of care21 and so a snapshot highlighting similarities and differences across study sites in answer to a specific question: How are ICU clinicians' experiences of HIT shaping the communications that support safe, high quality interprofessional care? Future research will need to inquire into whether the intuitions of our participants, and others, about the importance of face-to-face interactions are borne out as factors in patient outcomes such as length of stay, infection rates, errors rates, and mortality. While we have touched on the differences between more and less senior nurses as they made sense of HIT work and integrated it into their professional lives, our methods and analysis are not geared to deal with the potentially confounding role played by remembering, or never having known, a paper-based world prior to HIT. Our data set and so our analysis are unable to tease out broader trends in how junior and senior e digital native and digital immigrant e members of the interprofessional team may be differentially deploying cultural narratives to explain and justify the policy driven technical elements of their work world. Further research is needed to conduct this sort of analysis. While ethnographic findings can be dismissed as too anchored in their specific contexts to be generalizable to other sites, the dynamics we observed following the scientific precepts of the method were more similar than different across the ICUs we reported on here, and were confirmed by two different ethnographers. This, combined with the degree of concordance between our findings and others' regarding the way HIT can disrupt communications,33 as well as the extent, cognitive load, and unequal distribution of HIT work,30e32,36 suggests that our findings may well
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extend beyond the ICUs in our study. 6. Conclusion In the ICU environment, achieving policy goals of care team communication improvement via HIT systems requires attention both to clinicians' experiences of the new work, and how that work is distributed among ICU professionals. Particular attention is required to avoid returning to interprofessional relationships that privilege physicians at the expense of nurses, and build siloes rather than lines of communication. Funding This work was supported by the Gordon and Betty Moore Foundation. Acknowledgements The authors wish to thank Hanan Aboumatar, Simon Kitto, Peter Pronovost, and Scott Reeves for their assistance in the data collection phase of this research. References 1. US Department of Health and Human Services Hg. Certification and EHR Incentives: HITECH Act. http://www.healthit.gov/policy-researchersimplementers/hitech-act-0. Accessed January 20, 2014. 2. Blumenthal D. Launching HITECH. N. Engl J Med. 2010;362(5):382e385. 3. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N. Engl J Med. 2010;363(6):501e504. 4. Buntin MB, Jain SH, Blumenthal D. Health information technology: laying the infrastructure for national health reform. Health Aff. 2010;29(6):1214e1219. 5. Kaushal R, Blumenthal D. Introduction and commentary for special issue on health information technology. Health Serv Res. 2014;49(1 Pt 2):319e324. 6. Mechanic D. Rethinking medical professionalism: the role of information technology and practice innovations. Milbank Q. 2008;86(2):327e358. 7. Technology OotNCfHI. In: Services HaH, ed. Health it Enabled Quality Improvement: A Vision to Achieve Better Health and Health Care. 2014. Washington, DC. 8. Electronic Health Records: The New Lightning Rod in Health Care [computer Program]. The Commonwealth Fund; 2014. 9. Wachter RM. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age. New York, NY: McGraw Hill Education; 2015. 10. Mitchell G, Porter S, Manias E. A critical ethnography of communication processes involving the management of oral chemotherapeutic agents by patients with a primary diagnosis of colorectal cancer: study protocol. J Adv Nurs. 2015;71(4):922e932. 11. Rankin JM. The rhetoric of patient and family centred care: an institutional ethnography into what actually happens. J Adv Nurs. 2015;71(3):526e534. 12. Paradis E, Leslie M, Puntillo K, et al. Delivering interprofessional care in intensive care: a scoping review of ethnographic studies. Am J Crit Care. 2014;23(3):230e238. 13. Bijker WE. Of Bicycles, Bakelites, and Bulbs: Toward a Theory of Sociotechnical Change. Cambridge, Mass. ; London: MIT Press; 1995. 14. Bijker WE, Law J. Shaping Technology/building Society : Studies in Sociotechnical
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