Health information exchange technology on the front lines of healthcare: workflow factors and patterns of use

Abstract

Objective: The goal of this study was to develop an in-depth understanding of how a health information exchange (HIE) fits into clinical workflow at multiple clinical sites.

Materials and methods: The ethnographic qualitative study was conducted over a 9-month period in six emergency departments (ED) and eight ambulatory clinics in Memphis, Tennessee, USA. Data were collected using direct observation, informal interviews during observation, and formal semi-structured interviews. The authors observed for over 180 h, during which providers used the exchange 130 times.

Results: HIE-related workflow was modeled for each ED site and ambulatory clinic group and substantial site-to-site workflow differences were identified. Common patterns in HIE-related workflow were also identified across all sites, leading to the development of two role-based workflow models: nurse based and physician based. The workflow elements framework was applied to the two role-based patterns. An in-depth description was developed of how providers integrated HIE into existing clinical workflow, including prompts for HIE use.

Discussion: Workflow differed substantially among sites, but two general role-based HIE usage models were identified. Although providers used HIE to improve continuity of patient care, patient-provider trust played a significant role. Types of information retrieved related to roles, with nurses seeking to retrieve recent hospitalization data and more open-ended usage by nurse practitioners and physicians. User and role-specific customization to accommodate differences in workflow and information needs may increase the adoption and use of HIE.

Conclusion: Understanding end users' perspectives towards HIE technology is crucial to the long-term success of HIE. By applying qualitative methods, an in-depth understanding of HIE usage was developed.

Figure 1

Study design.

Figure 2

Health information exchange-related common workflow patterns. ED, emergency department.

Figure 3

Nurse-based workflow elements. HIE, health information exchange; HIT, health information technology; MD, physician; MSeHA, MidSouth eHealth Alliance.

Figure 4

Physician-based workflow elements. ED, emergency department; HIE, health information exchange; HIT, health information technology; MD, physician; MSeHA, MidSouth eHealth Alliance; NP, nurse practitioner; PA, physician assistant.