Electronic health record-supported implementation of an evidence-based pathway for perioperative surgical care

Abstract

Objectives: Enhanced recovery pathways (ERPs) are evidence-based approaches to improving perioperative surgical care. However, the role of electronic health records (EHRs) in their implementation is unclear. We examine how EHRs facilitate or hinder ERP implementation.

Materials and methods: We conducted interviews with informaticians and clinicians from US hospitals participating in an ERP implementation collaborative. We used inductive thematic analysis to analyze transcripts and categorized hospitals into 3 groups based on process measure adherence. High performers exhibited a minimum 80% adherence to 6 of 9 metrics, high improvers demonstrated significantly better adherence over 12 months, and strivers included all others. We mapped interrelationships between themes using causal loop diagrams.

Results: We interviewed 168 participants from 8 hospitals and found 3 thematic clusters: (1) "EHR difficulties" with the technology itself and contextual factors related to (2) "EHR enablers," and (3) "EHR barriers" in ERP implementation. Although all hospitals experienced issues, high performers and improvers successfully integrated ERPs into EHRs through a dedicated multidisciplinary team with informatics expertise. Strivers, while enacting some fixes, were unable to overcome individual resistance to EHR-supported ERPs.

Discussion and conclusion: We add to the literature describing the limitations of EHRs' technological capabilities to facilitate clinical workflows. We illustrate how organizational strategies around engaging motivated clinical teams with informatics training and resources, especially with dedicated technical support, moderate the extent of EHRs' support to ERP implementation, causing downstream effects for hospitals to transform technological challenges into care-improving opportunities. Early and consistent involvement of informatics expertise with frontline EHR clinician users benefited the efficiency and effectiveness of ERP implementation and sustainability.

Keywords: clinical pathway; electronic health records; health plan implementation; patient safety; perioperative care.

Figure 1.

High performers’ causal loop diagram. Key feedback loops for High performers portraying how qualitative themes under EHR Difficulties (solid-lined circles), EHR Enablers (dashed-lined circles), and EHR Barriers (dotted-lined circles) affected ERP implementation success. “B” describes balancing loops that include both + and − arrows. Arrows with a + sign indicate variables that increase or decrease together. Arrows with a − sign indicate variable relationships where increase (decrease) in one means decrease (increase) in the other.

Figure 2.

High improvers’ causal loop diagram. Key feedback loops for high improvers portraying how qualitative themes under EHR Difficulties (solid-lined circles), EHR Enablers (dashed-lined circles), and EHR Barriers (dotted-lined circles) affected ERP implementation success. “B” describes balancing loops that include both + and − arrows. Arrows with a + sign indicate variables that increase or decrease together. Arrows with a − sign indicate variable relationships where increase (decrease) in one means decrease (increase) in another.

Figure 3.

Strivers’ causal loop diagram. Key feedback loops for Strivers portraying how qualitative themes under EHR Difficulties (solid-lined circles), EHR Enablers (dashed-lined circles), and EHR Barriers (dotted-lined circles) affected ERP implementation success. “B” describes balancing loops that include both + and − arrows. “R” describes reinforcing loops that only include + arrows. Arrows with a + sign indicate variables that increase or decrease together. Arrows with a − sign indicate variable relationships where increase (decrease) in one means decrease (increase) in another. A hashed line on an arrow indicates a delay in effect.