Awareness of the Care Team in Electronic Health Records

Summary

Objective: To support collaboration and clinician-targeted decision support, electronic health records (EHRs) must contain accurate information about patients’ care providers. The objective of this study was to evaluate two approaches for care provider identification employed within a commercial EHR at a large academic medical center.

Methods: We performed a retrospective review of EHR data for 121 patients in two cardiology wards during a four-week period. System audit logs of chart accesses were analyzed to identify the clinicians who were likely participating in the patients’ hospital care. The audit log data were compared with two functions in the EHR for documenting care team membership: 1) a vendor-supplied module called “Care Providers”, and 2) a custom “Designate Provider” order that was created primarily to improve accuracy of the attending physician of record documentation.

Results: For patients with a 3–5 day hospital stay, an average of 30.8 clinicians accessed the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants. The Care Providers module identified 2.7 clinicians/patient (1.8 attending physicians and 0.9 nurses). The Designate Provider order identified 2.1 clinicians/patient (1.1 attending physicians, 0.2 resident physicians, and 0.8 physician assistants). Information about other members of patients’ care teams (social workers, dietitians, pharmacists, etc.) was absent.

Conclusions: The two methods for specifying care team information failed to identify numerous individuals involved in patients’ care, suggesting that commercial EHRs may not provide adequate tools for care team designation. Improvements to EHR tools could foster greater collaboration among care teams and reduce communication-related risks to patient safety.

Keywords

Provider communication - care team - electronic health records - health information technology - patient care team

 

• References

• 1 Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med 2004; 140: 1025-1033.
• 2 McKnight L, Stetson PD, Bakken S, Curran C, Cimino JJ. Perceived information needs and communication difficulties of inpatient physicians and nurses. Proc AMIA Symp 2001: 453-457.
• 3 O’Malley AS, Grossman JM, Cohen GR, Kemper NM, Pham HH. Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Intern Med 2009; 25 (03) 177-185.
• 4 Bardram JE, Bossen C. A web of coordinative artifacts: collaborative work at a hospital ward. In Proceedings of the International ACM SIGGROUP Conference on Supporting Group Work, GROUP ‘05: 2005; 168-176.
• 5 Blumenthal D. Launching HITECH. N Engl J Med 2010; 362 (05) 382-385.
• 6 Health Information Technology Policy Committee. Meaningful use workgroup request for comments regarding meaningful use stage 2. Available at: http://healthit.hhs.gov/media/faca/ MU_RFC%20_2011–01–12_final.pdf Accessed 19 May 2011.
• 7 Patel VL, Cytryn KN, Shortliffe EH, Safran C. The collaborative health care team: the role of individual and group expertise. Teach Learn Med 2000; 12 (03) 117-132.
• 8 Tang C, Carpendale S. Supporting nurses’ information flow by integrating paper and digital charting. In: Proceedings of the European Conference on Computer Supported Cooperative Work (ECSCW). 2009. Vienna; Austria: Sept 7–11 43-62.
• 9 Kannry J, Moore C. MediSign: using a web-based signout system to improve provider identification. Proc AMIA Symp 1999: 550-554.
• 10 Wong HJ, Caesar M, Bandali S, Agnew J, Abrams H. Electronic inpatient whiteboards: improving multidisciplinary communication and coordination of care. Int J Med Inform 2009; 78 (04) 239-247.
• 11 Carroll JM, Neale DC, Isenhour PL, Rosson MB, McCrickard DS. Notification and awareness: synchronizing task-oriented collaborative activity. International Journal of Human-Computer Studies 2003; 58: 605-632.
• 12 Carroll JM, Rosson MB, Convertino G, Ganoe C. Awareness and teamwork in computer supported collaborations. Interacting with Computers 2006; 18: 21-46.
• 13 Viégas FB, Donath JS. Chat circles. In: Proceedings of the ACM SIGCHI Conference on Human Factors in Computing Systems, CHI ‘99 1999; 9-16.
• 14 Tang J, Yankelovich N, Begole J, Van Kleek M, Li F, Bhalodia J. ConNexus to awarenex: extending awareness to mobile users. In: Proceedings of the ACM 28th International Conference on Human Factors in Computing Systems, CHI ’10: 2001; 221-228.
• 15 Buxton WAS, Sellen AJ, Sheasby MC. Interfaces for multiparty video conferences. In: Finn KE, Sellen AJ, Wilbur SB. (Eds.). Video-mediated communication. Mahwah, NJ: Lawrence Erlbaum Associates; 1997: 385-400.
• 16 McGrath JE. Groups: interaction and performance. Inglewood, NJ: Prentice Hall, Inc.; 1984
• 17 Arrow H, McGrath JE, Berdahl JL. Small groups as complex systems: formation, coordination, development, and adaptation. Beverly Hills, CA: Sage Publications; 2000
• 18 Bodker S. Applying activity theory to video analysis: how to make sense of video data in human-computer interaction. In: Nardi BA. (Ed.), Context and consciousness: activity theory and human-computer interaction. Cambridge, MA:: MIT Press; 1996: 147-174.
• 19 Bardram J. Designing for the dynamics of cooperative work activities. In: Proceedings of the ACM Conference on Computer Supported Cooperative Work. CSCW ’98: 1998: 89-98.
• 20 Hripcsak G, Vawdrey DK, Fred MR, Bostwick SB. Use of electronic clinical documentation: time spent and team interactions. J Am Med Inform Assoc 2011; 18 (02) 112-117.
• 21 Wilcox L, Morris D, Tan D, Gatewood J. Designing patient-centric information displays for hospitals. In CHI ’10: Proceedings of the ACM 28th International Conference on Human Factors in Computing Systems. 2010: 2123-2132.
• 22 Vawdrey DK, Wilcox L, Collins SA, Bakken S, Feiner S, Restaino SW. Patient use of a tablet computer to participate in hospital care. Proc AMIA Annu Fall Symp, 2011 (to appear).
• 23 Chen ES, Cimino JJ. Patterns of usage for a Web-based clinical information system. Stud Health Technol Inform 2004; 107 Pt 1 18-22.
• 24 Bowers L. The significance of primary nursing. J Adv Nurs 1989; 14 (01) 13-19.
• 25 Stead W, Lin H. (eds.). Computational technology for effective health care: immediate steps and strategic directions. Washington, DC: National Academies Press,; 2009
• 26 Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA. et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324 (06) 377-384.
• 27 Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care 2006; 15 (04) 235-239.
• 28 Coiera E, Tombs V. Communication behaviours in a hospital setting: an observational study. BMJ 1998; 316 (7132) 673-676.
• 29 Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events?. Ann Intern Med 1994; 121 (11) 866-872.
• 30 Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 1998; 24 (02) 77-87.
• 31 Wasson JH, Sauvigne AE, Mogielnicki RP, Frey WG, Sox CH, Gaudette C, Rockwell A. Continuity of out-patient medical care in elderly men. A randomized trial. JAMA 1984; 252 (17) 2413-2417.
• 32 Ways M, Umali J, Buchwald D. Frequency and impact of housestaff contact with primary care physicians. J Gen Intern Med 1995; 10 (12) 688-690.
• 33 Neher JO, Kelsberg G, Oliveira D. Improving continuity by increasing clinic frequency in a residency setting. Fam Med 2001; 33 (10) 751-755.
• 34 Maviglia SM, Yoon CS, Bates DW, Kuperman G. KnowledgeLink: impact of context-sensitive information retrieval on clinicians’ information needs. J Am Med Inform Assoc 2006; 13 (01) 67-73.
• 35 Rind DM, Safran C, Phillips RS, Wang Q, Calkins DR, Delbanco TL. et al. Effect of computer-based alerts on the treatment and outcomes of hospitalized patients. Arch Intern Med 1994; 154 (13) 1511-1517.
• 36 Hiltz FL, Teich JM. Coverage List: a provider-patient database supporting advanced hospital information services. Proc Annu Symp Comput Appl Med Care 1994: 809-813.
• 37 Kuperman GJ, Teich JM, Bates DW, Hiltz FL, Hurley JM, Lee RY. et al. Detecting alerts, notifying the physician, and offering action items: a comprehensive alerting system. Proc AMIA Annu Fall Symp 1996: 704-708.
• 38 O’Leary KJ, Kulkarni N, Landler MP, Jeon J, Hahn KJ, Englert KM, Williams MV. Hospitalized patients’ understanding of their plan of care. Mayo Clin Proc 2010; 85 (01) 47-52. Erratum in: Mayo Clin Proc 2010; 85(2): 205.
• 39 Clever SL, Jin L, Levinson W, Meltzer DO. Does doctor-patient communication affect patient satisfaction with hospital care? Results of an analysis with a novel instrumental variable. Health Serv Res 2008; 43 (5p1) 1505-1519.
• 40 Elwyn G, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract 2000; 50 (460) 892-899.
• 41 Fogarty LA, Curbow BA, Wingard JR, McDonnell K, Somerfield MR. Can 40 seconds of compassion reduce patient anxiety?. J Clin Oncol 1999; 17 (01) 371-379.
• 42 Fuertes JN, Mislowack A, Bennett J, Paul L, Gilbert TC, Fontan G, Boylan LS. The physician-patient working alliance. Patient Educ Couns 2007; 66 (01) 29-36.
• 43 Bakken S, Holzemer WL, Brown MA, Powell-Cope GM, Turner JG, Inouye J, Nokes KM, Corless IB. Relationships between perception of engagement with health care provider and demographic characteristics, health status, and adherence to therapeutic regimen in persons with HIV/AIDS. AIDS Patient Care STDS 2000; 14 (04) 189-197.
• 44 Thom DH, Hall MA, Pawlson LG. Measuring patients’ trust in physicians when assessing quality of care. Health Aff (Millwood) 2004; 23 (04) 124-132.
• 45 O’Farrell P, Murray J, Hotz SB. Psychologic distress among spouses of patients undergoing cardiac rehabilitation. Heart Lung 2000; 29 (02) 97-104.
• 46 Burker EJ, Evon D, Loiselle MM, Finkel J, Mill M. Planning helps, behavioral disengagement does not: coping and depression in the spouses of heart transplant candidates. Clin Transplant 2005; 19 (05) 653-658.
• 47 Hannemann-Weber H, Kessel M, Budych K, Schultz C. Shared communication processes within health care teams for rare diseases and their influence on health care professionals’ innovative behavior and patient satisfaction. Implement Sci 2011; 6 (01) 40.