The results will be reported at three levels of analysis. The first level presents the basic tasks that clinicians reported actually doing. These include the exact stated items, such as “Identify when the patient was last here” or “Determine the reason for the visit.” The second level is a common components analysis where we extracted common structures across tasks. The third analysis is at the goal level where generalized information management strategies and over-arching information management goals are identified.
Although we grouped similar tasks together to form categories, the basic wording was kept as close as possible to the original clinician’s reports as possible. A list of representative reported tasks (not the complete list) is displayed in . The list is organized chronologically starting with activities that occur at the beginning of the day, followed by tasks associated with seeing the patient, those involving follow-up or tracking over time as well as general ongoing time management actions. As a result, some tasks appear twice, such as “determine what medications the patient is on” and “recent medical activity.” This action occurs both prior to a visit and during a visit.
In order to identify the relationship between tasks and available computerized functionality, we coded each task along six available mediums. CPRS refers to the patient information system display normally used by providers. CM refers to Care Management, a new multi-patient view. VistA refers to the screen that allows entrance to all of the VA computerized systems, and includes not only clinical programs, such as lab, radiology, and others, but also employee time tracking, provider education, and patient scheduling. Paper referred to either lists manually written, spreadsheets created by providers and printed, or lists printed out from VistA. The Phone column is self-explanatory. The Person category not only includes in-person conversations, but also e-mails. The cells were color coded to reflect coverage of tasks. Grey in the cell indicates the task is partially covered by the medium. Black indicates full coverage and white indicates little or no coverage.
When scanning across the table, it appears that most tasks have some technical support, either from CPRS, VistA, CM, or all three. However, very few were completely supported. Even something as straightforward as determining the patient’s actual medication profile was frustrating for clinicians because not all drugs are listed in the VA profile (especially non-VA drugs) and the actual dosage may have been changed, but a new order was not really entered. And, some tasks required manual extraction and storage on paper, such as tracking a patient’s preparation for outpatient surgery. The data could be extracted from CPRS or VistA, but the overview display of the information required that it be taken down on paper. Having to move from medium to medium was one of the most salient complaints regarding the information system heard during the interviews. Many of the tasks were done differently from site to site and those were usually the rows with all gray cells (indicating some support with no single medium providing full support).
Common Components Analysis
Common components across tasks were abstracted from the list of tasks in using an iterative process of abstraction. presents the common abstracted structure. First, all tasks require some cue to begin. Most of the time, the cue is the well-learned ordering sequence of procedures. For example, the cue to schedule an appointment often arises from the normal routine care of the patient. The patient finishes their appointment and knows to go to the check out desk and the appearance of the patient in front of the clerk asking for a next appointment cues the clerk. However, the cue to schedule an appointment could also come from reading an electronic note from another provider suggesting the need for a consult or the nurse’s putting a note on the provider’s door reporting on a phone call. In any scenario, the simple task of scheduling an appointment becomes a collaborative effort; the physician has to indicate that one is needed, the nurse may have to identify for the clerk the appropriate time, the patient has to know about the need for an appointment and the clerk has to actually enter the time into the computer. At each step, the previous action provides the cue for the next step and often, different individuals will do each component. Interestingly, the specific form that a sequence of cues would take was unique (but consistent) for each site and embedded into local workflow. However, the exact work processes used varied across sites.
Table 2 Common Task Components
The second common component is status. Tasks can be pending, in progress, ready to be communicated, or resolved. Status is an aspect of tasks that needs to be tracked continuously. Everyone sharing in a task requires this information. Tracking the status of tasks is a regular and repetitive component of workflow. The lack of a simple way to track the status of ongoing tasks was a common complaint and often would require substantial searching on the part of the provider. Resolved is a status that a task can take and because every task has a unique and complex manner of completion, the resolved status could be multi-faceted. Examples of types of resolutions include writing in the chart, communicating to another provider, communicating to the patient, and finishing the task itself. Commonly, the task has to be “crossed-off” from personal overview planning lists (which nearly every provider has) in addition to the other resolution actions.
Third, all tasks have a time component, including when they are due, length of time to complete the task (a test can be ordered, but scheduling requires a 2-week wait) or in the case of repetitive tasks (e.g., ordering monthly narcotics), the time interval. Often everyone in the clinic knows the time component implicitly because it is commonly held clinical knowledge (e.g., the time from a Coumadin change to the next INR test). Time information is an integral part of interpreting information and is always sought after if it is not available. When the information is not so clearly known, such as how long it has been since a patient has been called, or how many times a test has been repeated, then providers often need to resort to verbal communication.
Fourth, every task has an owner or owners. Identifying task ownership was a common information need. Unfortunately, in the current information system, identifying who owns the task is difficult, except when it is a formal order (which is only a small part of the communicated information). Not only does every task have an owner, but also as tasks evolve, sometimes the owner would change. Often, tasks involve significant coordination of activities between individuals. For example, the different tasks created as part of the process of getting an outpatient ready for surgery requires the primary care provider to provide a history and physical, nurses must schedule the surgery based on patient’s needs, clerks must determine the schedule and order protocol labs and other nurses must ensure that education is done and consents signed. Often, the person with whom the responsibility is shared is known by name, other times only by role. Determining the name of the person in a designated role is information that is currently not available on the computer and often requires substantial time to determine.
Most importantly, nearly all tasks require some form of communication to another person in the workplace. Usually this communication goes beyond simply documenting it in the notes. The material to be communicated varies, but may include one or more of the following: content, state, the responsible individual, and time. Tasks vary in the degree to which communication is an inherent component of the process, but often in order to get something done, another person has to be contacted. For many tasks, communication is central, getting an appointment means telling the patient, the clerk, and maybe the nurse when, why, and maybe even how to make the appointment. The triage nurse takes every patient interaction and often must contact 3–4 individuals before she can go on to the next patient’s call.
Some forms of communication are standardized in medical practice, such as orders and consults. Many others are less structured but are so embedded into workflow that clinicians are usually not aware of them. The variety, complexity, and idiosyncratic nature of local procedures for sharing information among providers were quite surprising. For example, the physician may not formally request that the intake nurse ask questions about medications or symptoms, but expects that those questions are asked and infers that if he or she does not get notified, there were no problems. When a patient calls in, the nurse answering the call makes a decision regarding the severity of the problem, which provider or providers should be told and when. Local procedures determine whether a decision is made by protocol, whether the physician is phoned, or whether an e-mail is sent. In some clinics, the nurse conducts an intake interview, in others a clerk asks the patients an initial set of questions and in still others, no initial interview takes place. Results from the interview may be written in a note, handwritten and taped to the door, written on paper and given to the patient, or simply communicated verbally. Sometimes several of these forms would be taking place at once.
In addition, every communication requires feedback and confirmation. Staff would go to great lengths with complicated work-arounds to ensure that their communications were received. These work-arounds ranged from requiring initials on a paper being physically passed from provider to provider to assigning a specific provider as a co-signer on an electronic note (meaning that an alert would be sent to the receiver notifying him or her of an incoming communication requiring signature).
Finally, most tasks are linked to other tasks. Specifying the links between tasks as well as role and time dependencies prior to the initiation of the task is part of planning care and an intricate component of the implementation of sequences of care, such as guidelines. Because the links must be explicit, observable, and traceable, they are often recorded on paper, such as personal lists of patients requiring follow-up, formal tracking sheets for Coumadin patients that are posted, or lists of patients who need narcotic renewals. Progress notes are rarely used because they cannot be updated and cannot be linked. Neither CPRS nor CM support detailed specification of task linkage, nor is there a common “work board” to which all relevant providers could refer.
Information Management Goals
Four general categories () of information management goals emerged from the analysis. The higher-level goals are generalized patterns of strategies that resulted from extensive analysis of the transcripts. They are complex behavioral patterns that bridge the human, work processes, and the computer. Although similar goals are present across individuals, the exact strategy(ies) may differ significantly. At times these strategies are episodic and observable, but more often they are implicit, that is they are completely embedded into the work processes. Often, providers would not be aware of them and only extensive questioning would reveal their presence. In most cases, these high-level information-processing goals were only apparent to the investigators after intensive reviews of the transcripts.
Table 3 Information Management Goals
The first goal, Relevance Screening included strategies to narrow the field of attention by setting up mechanisms to screen, sort, and prioritize information. These kinds of strategies were the most numerous. For example, providers would report having the clerks add the reason for the visit into the scheduling package so that they would not have to search the notes looking for a likely reason for the upcoming visit during preparation time. Every day a clinic list would be printed for all staff and the list contained the reason. Or, providers might customize their notification screen so that only the highest priority alerts would be visible on the notification window, thereby removing minimizing sorting effort. Selectively screening notes based on knowing the provider (Dr. Smith is known to be accurate and thorough) or using only one’s own notes was very common. With over 100 notes displayed in chronological order, being able to read only a few notes at a time is an important time saver. Since electronic notes can be considerably longer than written notes, taking the time to scan through all of the notes can become almost impossible. Of course, recent ER notes would be read as well as recent results from selected consults. Because of the amount and density of the information, most providers would have to resort to personally writing on paper important highlights from the patient history. They would avoid large categories of notes if they believed that the amount of material presented would not contain sufficient relevant information given the effort. For example, most providers reported avoiding notes that used templates altogether (which included many nursing notes). Other times, the strategy would exist at the whole clinic level, such as having all alerts sent to a covering or triage nurse. The nurse assigned to the task would then sift through the alerts and communicate only the most acute or important items. The overarching goal with this strategy is to minimize the information overload that accompanies the use of an electronic record.
The next category, called Ensuring Accuracy seemed almost the opposite strategy and included actions to increase the available information. The underlying goal of this group of strategies appeared to be to ensure accuracy and completeness. Many providers expressed significant distrust in the accuracy of the system and would try to build in redundancy. Some providers would have the results of all of their orders alerted back to them to avoid missing important information or have clinic nurses review daily labs and alert them of patient problems. Or, they might copy the entire results of lab panels, procedures, or x-rays into open progress notes as a reference when they are talking to the patient and then delete the ones not used for the final completion of their notes in order to ensure that they did not miss anything. Some providers would give out their personal number to make sure that the patient could get in contact with them directly or would set up clinic systems to call every patient following a visit. Calling the specialist after making a referral was often done to make sure that they understood the reason for the consult. The simplest form of this group of strategies is the ubiquitous scanning of all sources of information, ranging from the numerous electronic notes, VISTA, e-mail, and paper notes. Of course, there were significant individual differences between providers. The overarching goal associated with these sets of strategies is to maximize certainty and confidence in their retrieval of information.
The third category, Minimizing Memory Load, included strategies to set up personal reminder systems or to keep track of required tasks over time. A large variety of strategies were used for this purpose, such as a provider’s creating an unsigned addendum or progress note as a reminder to complete a task (providers receive alerts about unsigned notes). Another strategy in this category was to use the VistA e-mail to send oneself a message on a specific date. Or, a fake clinic might be created filled with appointments of patients requiring follow-up (a clinic list can then be scanned and reviewed by everyone and comes up on a pre-determined day). The patients listed in one fake clinic were those needing monthly refill of narcotics for a single provider, thereby allowing the names to come up on his appointment list for that clinic on that day. Almost all providers kept a paper “to do” list for the day, marking off tasks as they were finished and adding others as they came up. Paper calendars would be used because they could be posted and serve as highly salient visual cues. Finally, every clinic had numerous visual aids that would cue staff as to whom the patient had seen, who would be seeing the patient next, and what was left to do for that patient’s appointment. These reminders were largely in the form of check-off lists, patient folders located in different places, and names written and erased on boards visible to all.
The fourth category, Negotiating Responsibility, included a variety of processes to assign tasks or negotiate hand-offs. There are basically two kinds of hand-offs, within roles and between roles. Nurses and physicians generally divide up the workload according to standard roles, although there is a great deal of gray area between the two. Nurses would write orders and conduct procedures without orders if that was standard clinic practice. No clinic was alike in terms of the extent to which protocols were used. Other providers (such as physical therapy, social work, or dieticians) would be assigned the patient using a variety of mechanisms. Sometimes, ordering providers would simply write that they wanted the social worker to see the patient in a progress note, expecting that the social worker would read it (as a member of the team). Other times, the assignment would be done through e-mails, creation of a virtual clinic that was attached to that provider, or more formally through the CPRS consult package. The diversity in procedures between clinics was notable. The need for administration to track workload was an important consideration in making these decisions.
Hand-offs within roles occurred either at change of shift (usually nurses) or between providers when one went on vacation or residents rotated off the clinic. These issues were dealt with differently at every site, but often required significant redirecting of alerts, re-organizing the team structure in the computer, and canceling or moving appointments. This process is quite complicated because most providers work in teams and so sometimes the whole team needs to be alerted. The management of teams is an older functionality of VISTA and coordinates the alerting and notification structure of CPRS. Interestingly, it became clear in our interviews that the mechanisms of team management (and how things were set up locally) were often only known by a very small number of individuals at each site, if at all. In addition, these procedures differed substantially across sites making it quite difficult for developers of new programs (e.g., Care Management) to understand standard practice in the field. Some sites had an individual in the clinic assigned to “manage” team lists. This person would ensure that every provider was on the correct list and when clinicians rotated in and out, the lists were updated. At other sites, the clinicians were taught how to put themselves on and off lists and were expected to manage it themselves. And, in other sites, the computer office alone provided list management.
In summary, providers were observed to be engaging in a wide variety of strategies that allowed them to effectively adapt to the computerized information environment. The overall goals of minimizing cognitive load, enhancing accuracy, remembering important information, and negotiating responsibility were noted. The specific strategies used to meet these goals varied significantly between individuals within a clinic and also substantially across clinics.