Unertl KM et al. 2006 "Applying direct observation to model workflow and assess adoption."

Unertl KM, Weinger MB, Johnson KB. Applying direct observation to model workflow and assess adoption. AMIA Annu Symp Proc 2006:794-798.
"Lack of understanding about workflow can impair health [information technology] system adoption. Observational techniques can provide valuable information about clinical workflow. A pilot study using direct observation was conducted in an outpatient chronic disease clinic. The goals of the study were to assess workflow and information flow and to develop a general model of workflow and information behavior. Over 55 hours of direct observation showed that the pilot site utilized many of the features of the informatics systems available to them, but also employed multiple non-electronic artifacts and workarounds. Gaps existed between clinic workflow and informatics tool workflow, as well as between institutional expectations of informatics tool use and actual use. Concurrent use of both paper-based and electronic systems resulted in duplication of effort and inefficiencies. A relatively short period of direct observation revealed important information about workflow and informatics tool adoption."

"To assess workflow and information flow [in an outpatient chronic disease clinic] and to develop a general model of workflow and information behavior."

Tools Used
Type Clinic
Specialty care
Type Specific
Multiple sclerosis care
Small and/or medium
Other Information
The study took place at a single subspecialty disease management clinic at Vanderbilt University Medical Center (VUMC) serving 2,500 patients.
Type of Health IT
Electronic medical records (EMR)
Type of Health IT Functions
"[The EMR] enables users to capture vital signs, medication lists, problem lists, and clinic notes at the point of care. [It] also has a message basket function that allows staff members to communicate electronically. Message baskets can be shared between users based on roles, such as a message basket for all nurses in a single clinic."
Context or other IT in place
"The clinic utilizes software for scheduling and billing and PACS software for viewing MRI scans."
Workflow-Related Findings
"Information originated from both inside and outside VUMC. The types of information included: laboratory results, MRI scans, medical records, and communications. Lab results arrived in the clinic electronically through [the EMR], by fax machine, by email, and also through hard copy either mailed by the testing location or brought in by the patient. Medical records included both [the EMR] and paper "shadow" charts maintained by and exclusive to the clinic."
"At one point, a form within [the EMR] used to collect data about patients' pain level and risk of domestic violence changed without advance warning. The paper form used in the clinic to actually collect these data was not updated until later, resulting in staff confusion and workflow disruption."
"There were problems with a message basket shared by the clinic's nursing staff. Two nurses worked on the same message in the shared basket without realizing the duplicated effort. Nurses noted that some messages were being removed from the basket by administrative staff in another clinic and sent to individual nurses, defeating the purpose of the shared basket. Nurses commented frequently about the high volume of messages in this basket and how difficult it was to actually respond to them all each day."
"Physicians had difficulty reviewing MRI scans done outside VUMC ... If patients brought a CD containing the images, the clinic was frequently unable to view the images. Proprietary viewers for myriad different MRI image formats could not be loaded on the clinical workstations in the examination rooms. The clinic only had one administrative workstation that could handle these applications but clinic staff was not aware that this software existed or could be installed on it."
"The informatics tool did not support the clinicians' need to integrate disparate clinical information to formulate a complete picture of patient status in the past, present, and future. Using the paper chart, physicians could quickly flip through previous neurological examination forms and see how the patient's status had changed over time. The presentation of the same data in the EMR appeared to be suboptimal for supporting this essential clinical need."
The EMR "was designed to be a care management tool and it was anticipated that paper charts would no longer be necessary once it was deployed. Yet in this clinic, [the EMR] is being used primarily as a data repository and shadow charts are still an integral part of the workflow. The presence of the informatics tool has increased workload, as effort is duplicated to maintain both types of records."
"During the handoff of the patient from the nurse to the physician, little communication took place. Some information that patients shared with the nurse was not communicated to the physician because the nurses recorded data in the EMR and the physicians rarely consulted the EMR. The shadow chart sometimes, but not always, mitigated this gap."
"The nurse copied data provided by patients from the paper forms into the EMR. The volume of data and the free text structure of the EMR made this a tedious and time-consuming process."
"This study identifies aspects of workflow that are complicated by, rather than complemented by, technology. This clinic adapted to meet an institutional mandate for a paperless office even though the provided technology did not fully support users' workflow. The results suggest that if clinical informatics tools are not designed with a detailed understanding of workflow, then adoption may be impaired."
Study Design
Study Participants
Clinical and administrative staff of the clinic participated.