Safran C et al. 1998 "Electronic communication and collaboration in a health care practice."

Safran C, Jones PC, Rind D, et al. Electronic communication and collaboration in a health care practice. Artif Intell Med 1998;12(2):137-151.
"Using cognitive evaluation techniques, this study examines the effects of an electronic patient record and electronic mail on the interactions of health care providers. We find that the least structured communication methods are also the most heavily used: face-to-face, telephone, and electronic mail. Positive benefits of electronically-mediated interactions include improving communication, collaboration, and access to information to support decision-making. Negative factors include the potential for overloading clinicians with unwanted or unnecessary communications."
"To apply cognitive evaluation techniques to the assessment of the effectiveness of clinical systems deployed in a health care practice."
Tools Used
Type Clinic
Primary care
Other Information
The study took place at Healthcare Associates, the outpatient primary care unit of Boston's Beth Israel Deaconess Medical Center.
Type of Health IT
Electronic health records (EHR)
Type of Health IT Functions
A computer system that "includes approximately 5000 computer terminals throughout every department of the hospital. Each department communicates via these terminals..., so that information is entered directly into the computer system and is then instantly available. E-mail is also available and heavily utilized ... and has become a key method of communication among the hospital staff. Additional features which provide support to the health care professionals include decision support programs in areas such as...medications, support in the care of patients with HIV, computer-based alerts to changes in condition, and assistance with determination of discharge medications...Alerts and reminders are a feature [of the system] which prompts providers that a particular intervention might be indicated for a particular patient. They appear automatically...and provide just-in-time triggers...Reminders differ from alerts only in that the messages in reminders are not important enough to interrupt workflow, whereas the information in an alert message may require urgent action."
Context or other IT in place
"A MEDLINE literature search program ... is also available [at the study site] and is used frequently."
Workflow-Related Findings
"Of the providers observed, most appreciated the presence of alerts and reminders and checked them regularly. Another perspective, seen more in expert practitioners, saw them as annoying in that they were unnecessary."
"The involvement of the computer [in the collaboration of the care team] is facilitated by its ready availability throughout [the practice] as well as from outside the hospital. When the team is discussing an issue, the computer is at the location and is included as a resource."
"The nature of data entry in a computer system allows for more efficient updating of records, such as problem lists and prescription lists. They do not have to be rewritten, or crossed off when no longer applicable."
"The large volume of e-mail observed (up to 100 messages per provider per day) might appear to some degree a sign of a successful application of technology. People use the email system extensively because they find it superior to other modes of communication for certain types of messages ... We feel the difficulties providers face is not the volume of mail but rather the appropriateness and relevance of the content of messages."
Using the computer system, communication "flow is not based on any visible hierarchy." There is an "egalitarian pattern. Communication centers on the goal of the interaction, with the content, and direction being determined by the nature of the expertise required and the caregiver who possesses it."
"Of the sample of 12 providers interviewed, 11 reported finding the computer a useful addition to their practice and an improvement over previous tools. The 12th provider later modified initially negative comments, stating that the computer's usefulness outweighed its drawbacks."
"A major advantage of the computer system observed during the delivery of patient care is the easy accessibility to information from any terminal...This is particularly useful for roles involving coordination of patient flow, such as Clinical Triage Nurses, Community Resource Specialists, Practice Assistants and Secretaries, in that they can...assess issues based on knowledge of the patients' histories."
"Unscheduled issues can be assessed quickly and efficiently, even during a phone call.... Appointments can be coordinated since everyone has access to appointment schedules of both patients and other providers."
"A popular feature of the [system] is the prescription reordering and printing, in which prescriptions do not have to be re-entered and re-written. Both steps can involve as little as a few key strokes, which is seen as a major advantage over paper methods. It also facilitates the maintenance of an updated list of medications in the medical record."
"A printout of portions of the [system] is also provided to providers during the patients' appointments. They were seen to rely on it heavily, referring to it during visits and making notes on it."
"Many clinical areas outside of the primary care practice do not utilize the on-line medical record for complete charting. This affects the inclusiveness of [the system] and creates frustration for the primary care providers when looking for records of departments that are not online."
"Easier access to information releases providers to attend to the patient and increases the resources and information available to do so. Examples include ordering medications, which no longer requires a hand-written prescription, the readily available Physician's Desk Reference, a well-known reference source for physicians' practice and the Formulary, a list of all medications that patients ask about, as well as maintaining an updated medication list, checking other appointments that the patient has booked or that a provider of interest has available, sending referrals and consults, and maintaining a readily available problem list. The system also provides teaching tools, such as the ability to print out information describing any medication in the Formulary, while the patient is available and without having to look through files, shelves and cabinets."
While working with patients, providers "have access to the medical record as well as planned appointments.... This access is extended to providers who are outside the hospital, allowing them to access the system from home, other offices and other institutions. This allows providers to prepare for appointments ahead of time, to follow up on expected results quickly, and to remain accessible and in communication while away from the unit."
"Initial observations show that the presence of the computer does affect the provider/patient interactions in subtle ways. The necessity of 'interacting' with the terminal is distracting, taking attention away from the patient. Providers were observed to have compensated for this by reviewing patient material prior to the appointments and by using the [system] printout provided rather than the [system] itself while actually with the patient."
The extent to which the system affects patient-provider interaction "relates very strongly to usability. The more interaction required by the system, the more distracting it is and the more likely providers are to resort to more traditional, familiar modes of functioning, i.e. paper records."
"Patient interviews showed no relationship between the amount of time providers spent with the computer and patient satisfaction. In fact, patients were uniformly positive about the system, though one patient reported that she had initially been leery of it."
Study Design
Only postintervention (no control group)
Study Participants
Staff and physicians in the outpatient primary care unit participated.