Using Health Information Technology in Practice Redesign: Impact of Health Information Technology on Workflow

The need for effective health information technology (IT) to manage electronic patient data and to support redesigned systems of ambulatory care has expanded as the number of providers using electronic health record (EHR) systems has grown. Yet health IT and the work systems it supports are not always compatible. Health IT-workflow interactions, best understood through a human factors and sociotechnical framework, have not been extensively or rigorously studied, and published research is not always informative to organizations seeking to use health IT systems to support redesign of their ambulatory care settings. To address this gap, this project evaluated the multiple work activities, roles, and technologies in six primary care practices that introduced new health IT tools in their redesign of care coordination.

The specific objective of the project was as follows:

• Understand the impact of implementing health IT-enabled care coordination on workflow within small community-based primary care clinics in various stages of practice redesign. 

A formal mixed-methods approach employed direct observation, patient and staff interviews and surveys, artifact and spatial data collection, and software use monitoring to study six site teams. The teams, located in primary care clinics at Vanderbilt University Medical Center, were in different phases of introducing My Health Team at Vanderbilt (MHTAV). MHTAV is a care coordination program that included a new care coordinator role and new health IT components called the MHT tools. In addition to using the existing Vanderbilt EHR system and patient portal, the MHTAV program added: 1) diabetes, hypertension, and congestive heart failure dashboards; 2) worklists used by the coordinators; 3) a plan of care for the patient; 4) a disease control form; 5) alerts and reminders; 6) a patient portal journal for sharing home monitoring information; and 7) an interactive voice response system. Iterative observations and supplemental data collected over 12 months for each site team were used to explore health IT-workflow interactions over time.

The overall impact of health IT on care coordination workflow was mixed, varying from good to neutral to poor, depending on the specific task, technology, user, and use of health IT. Five primary areas of care coordination work and two areas of supporting work were identified from analysis of interview and observation field notes. The primary work of the coordinators was: establishing and maintaining relationships with patients and a plan of care, collecting and analyzing home monitoring data, educating and coaching patients, and coordinating with other clinical staff and patients. Two additional activity areas supported their primary work: searching for information to support decisionmaking and action, and prioritizing tasks and planning work. Work in these seven areas was enabled by multiple forms of IT, including new health IT (MHT tools), existing health IT (the EHR, patient portal, online patient education materials, messaging, and online whiteboard), and general IT (scheduling system).