Analysing EHR navigation patterns and digital workflows among physicians during ICU pre-rounds

Abstract

Background: Some physicians in intensive care units (ICUs) report that electronic health records (EHRs) can be cumbersome and disruptive to workflow. There are significant gaps in our understanding of the physician-EHR interaction.

Objective: To better understand how clinicians use the EHR for chart review during ICU pre-rounds through the characterisation and description of screen navigation pathways and workflow patterns.

Method: We conducted a live, direct observational study of six physician trainees performing electronic chart review during daily pre-rounds in the 30-bed medical ICU at a large academic medical centre in the Southeastern United States. A tailored checklist was used by observers for data collection.

Results: We observed 52 distinct live patient chart review encounters, capturing a total of 2.7 hours of pre-rounding chart review activity by six individual physicians. Physicians reviewed an average of 8.7 patients (range = 5-12), spending a mean of 3:05 minutes per patient (range = 1:34-5:18). On average, physicians visited 6.3 (±3.1) total EHR screens per patient (range = 1-16). Four unique screens were viewed most commonly, accounting for over half (52.7%) of all screen visits: results review (17.9%), summary/overview (13.0%), flowsheet (12.7%), and the chart review tab (9.1%). Navigation pathways were highly variable, but several common screen transition patterns emerged across users. Average interrater reliability for the paired EHR observation was 80.0%.

Conclusion: We observed the physician-EHR interaction during ICU pre-rounds to be brief and highly focused. Although we observed a high degree of "information sprawl" in physicians' digital navigation, we also identified common launch points for electronic chart review, key high-traffic screens and common screen transition patterns.

Implications: From the study findings, we suggest recommendations towards improved EHR design.

Keywords: ICU; clinical work; electronic health records (EHR); health information management; workflow.

Figure 1.

Breakdown of screen visits by discrete EHR screen (n = 330 screen visits). The table (left) provides the granular data for the pareto chart (right). Discrete screens are listed by proportion of total screen visits, in descending order. EHR: electronic health record.

Figure 2.

Aggregate mapping of physician screen navigation pathways during pre-rounding chart review (n = 330 screen visits). Sequential EHR screen visits are mapped across six ICU physicians, reflecting the variable digital pathways taken by physician users performing electronic chart review for a single patient from start to end. Arrow thickness indicates relative frequency of navigation patterns. MAR: medication administration record; IO: ins and outs; Micro: microbiology; EHR: electronic health record; ICU: intensive care unit.

Figure 3.

Representative mapping of individual physician screen navigation pathways. Arrow thickness represents the frequency of a given navigation pathway. User 1 (panel a), reviewing 12 patient charts, demonstrates more variability with screen pathways, starting on one of the three screens and almost always routing through flowsheet. User 2 (panel b), reviewing 9 patient charts, demonstrates more homogeneity, starting exclusively with notes and never visiting the flowsheet. For 1 of the 9 patients, user 2 visits only one EHR screen (notes). MAR: medication administration record; IO: ins and outs; Micro: microbiology; EHR: electronic health record.

Figure 4.

Heat map matrix of aggregate screen transitions across physician users (n = 278 total screen transitions). Relative screen transition frequency is calculated in aggregate across all users. Screen transitions were identified and tabulated from the observed series of sequential screen visits as documented by research personnel using the study checklist instrument. MAR: medication administration record; IO: ins and outs; Micro: microbiology.