Our results demonstrated the strengths and the weaknesses of an existing HIT infrastructure. Although the EHR used in the study clinics is a locally developed system, the observed positive and negative attributes of the HIT systems and the implementation process are not unique to this environment. 49,50
Clinic staff and providers documented and tracked patient status over time. Many providers integrated the EHR into their routine workflow. However, the primary care orientation of the EHR design did not fully support the needs of chronic disease care providers. Based on our results in three diverse ambulatory clinics, we developed a framework of ten guidelines for the design and implementation of HIT solutions for chronic disease care ().
The key commonalities and significant differences among the clinics support a modular approach to HIT design for chronic disease care. Core functionality could support common needs across clinic environments including: tracking patient disease status over time, displaying previous treatments and responses to previous treatments, analyzing trends, assisting with patient education materials, and facilitating communication with patients and throughout each clinic. The core HIT functionality could be supplemented with disease-specific modules. For example, the types of information recorded in notes varied between clinics as a function of disease-related information requirements.
Specialized templates may be necessary to meet unique information needs. However, many components of disease-specific HIT modules could be repurposed for multiple clinics. For example, a generic nutrition module could be designed to support the needs of diverse specialty clinics (e.g., CF, DM, obstetrics, gastroenterology) where tracking dietary information is an important component of care. Additional specialized modules should include qualitative data tracking, tailored order entry and prescription writing, disease-specific self-management support, and graphical input elements (e.g., the homunculus would also be useful in neurology, orthopedics, and physical therapy). In addition to customizing technology to meet disease-specific needs, HIT design should support different users' needs. Clinic personnel collect and enter different types of data and have different information needs depending on their role and responsibilities within the clinic. Interfaces that could be customized to support individual workflow needs and preferences could improve efficiency, user satisfaction, and data quality.
As with any “engineering” process, it is vital to have proper design strategy. Developers and implementers did not have comprehensive requirements for each chronic disease clinic during initial EHR implementation; later phases of implementation did not include time to gather and incorporate this information into design. Although some modules to assist with chronic disease care had been developed, 51
the three clinics did not have access to these modules during the study period. Addressing new requirements as they arise in implementation is a necessity in user-responsive modular HIT development.
Entering information into existing HIT, especially during interaction with patients, was difficult for many providers. Barriers included lack of typing proficiency, data collection form design, and hardware placement. New input modalities, such as tablet computers and software-based solutions like graphical forms, should be developed and evaluated. Advanced speech recognition software could also facilitate data entry.
Data are entered into the EHR from multiple sources and in multiple formats including medical device downloads, scanned paper forms and handwritten notes, and information recorded electronically. As time passes, the volume of information in the EHR increases tremendously. Chronic disease care providers are routinely required to search and filter through this disparate collection of information in an attempt to find the data they need at a particular time; the EHR must facilitate this process. Providers also need to rapidly and accurately synthesize information to formulate a coherent picture of patient status over time and then to inform treatment decisions. Providing longitudinal views of patient disease history is a requirement of HIT for chronic disease care.
The study also highlighted the challenges of HIT adoption in chronic disease care. Our results demonstrated that end users will create inefficient, but policy-compliant, workarounds to accomplish tasks when the HIT does not meet their needs. 52
Perception of system impact on time and workflow can be as important as the actual impact itself. Barriers to adoption must be investigated and addressed to bridge implementation chasms. 53
The inadequate transfer of knowledge among HIT designers, implementation teams, and end users can inadvertently create barriers to adoption. Multiple providers stated that they were aware of or proficient in using only a small fraction of the EHR's functionality. Finding better ways to help end users become proficient with the EHR features they need, including addressing user interface design challenges, would enhance technology adoption.
This study provides a picture of workflow, information flow, and computer use in three chronic disease clinics at one Academic Medical Center. We selected qualitative methods based on the research questions. Quantitative methods such as time-motion studies could supplement the understanding of aspects of workflow in ambulatory chronic disease care. A single researcher (KMU) collected the data, introducing the potential for observer bias. To address this potential limitation, study procedures and data were extensively reviewed and refined by the entire research team. In addition, interviews were conducted with clinic personnel to obtain feedback on the validity of observations and conclusions as a form of member-checking. 54
The three clinics all used the same EHR system. Researchers previously documented high levels of satisfaction among primary care providers using this same EHR, 55
but before this study little was known about usage patterns and satisfaction among specialty care providers. A different EHR system would likely impact workflow in different ways, underscoring the need for additional qualitative research to triangulate the needs of specialty care providers. Chronic disease care was only studied in disease-specific clinics, yet primary care physicians also provide chronic disease care. Changes to policies, procedures, staff, and informatics tools were implemented during the course of the study. While the dynamic nature of the work environment presented challenges, we collected data on these changes as part of the study and incorporated this information into our analysis.