Impact of Meaningful Use on Clinical Workflow in Emergency Departments

Advances in electronic health records (EHRs) can reduce clinician burden and improve the quality, safety, and efficiency of healthcare. Federal incentives have stimulated the adoption of EHRs and stages of “meaningful use” (MU) implementation have been established. As EHRs have become prevalent, measuring the impact on clinical workflow is increasingly important. Early reports from hospitals and governing bodies experienced with Stage 1 MU implementation called for external evaluation of MU criteria before implementing future stages.

Clinicians providing emergency care need EHRs that are fast, intuitive, and aligned with clinical workflow. However, many EHRs were developed and tested by information technology developers and were not assessed for usability by healthcare providers in a clinical setting. Poorly designed EHRs can lead to errors in care that risk patient safety. This mixed methods research investigated the impact of MU on clinical workflow in two emergency departments (EDs) using different EHRs and developed recommendations to improve EHRs and patient safety.

The specific aims of the research were as follows:

• To investigate patterns of clinicians’ use of EHRs within the ED workflow with specific emphasis on information-seeking behaviors, team interactions, and clinical decision making, while the organization is addressing Stages 1 and 2 of MU criteria requirements. 
• To evaluate the changes in a set of four clinical quality and efficiency metrics both prior to and post MU implementations for Stages 1 and 2, and trace the potential contribution of the changes in the metrics to the aspects of clinical workflow identified in Aim 1. 
• To develop contextually plausible and relevant patient safety and quality guidelines for EHR improvement that may be suitable for incorporation into future MU stages. 

The research team assessed and compared EHR use in EDs at academic and community-based settings through semistructured interviews with providers, ethnographic observations, shadowing clinicians, EHR data logs, and radio frequency identification sensor-based tracking. Analyses indicated that changes in clinical workflow with EHR implementation were influenced by the nature of clinicians’ tasks, as dictated by specific organizational contexts. At the academic health centers, providers saw several patients concurrently, resulting in a more chaotic workflow and providers spending more time using the EHR for documentation. In comparison, the providers working in community settings had a more linear workflow because they saw one patient at a time.

The research team concluded that the complexity and demands placed upon physicians in academic ED settings resulted in more team communication, interruptions, and multitasking. While these factors were found to compromise safety by increasing cognitive load, the collective knowledge and expertise of the team provided greater opportunity for error detection and correction. To leverage EHRs in the ED without compromising safety, the team recommended: 1) using automation, such as tracking devices, to increase efficiency; 2) using scribes to support clinical documentation of patient visits to increase efficiency and reduce physician burnout, but noted that this may increase errors unless providers review the documentation; and 3) building support for data capture in real-world clinical environments, for example generic templates that can be used from a mobile device.