In this chapter
There is much in common between the enterprise systems that were the subject of Chapter 6 and the clinical support systems that are the subject of this chapter. The most important difference is that a workaround or the use of shadow IT could compromise the well-being of a patient, even to the stage of a fatality. As a result there seems to be a much more proactive approach to identifying workarounds and in particular assessing whether these workarounds should be incorporated into the design and operation of the clinical support system. In general there seems to be more openness in this sector, with detailed reports on implementation issues and a number of major conferences.
An overview of clinical support applications
In the business environment there are decades of experience in implementing and managing enterprise applications, largely based on previous experience within the organisation. The concept of Electronic Health Record applications for primary and secondary healthcare organisations is by comparison quite novel and general practitioners (primary) and hospitals (secondary) have had to start from not only a blank sheet of paper but indeed largely paper-based systems.
The scale of the work involved in implementing these applications puts considerable strain on the IT resources of the facility, with external systems integrators playing a major role in the implementation. The training requirement is immense within clinical situations which need to provide 24/7 levels of care with a limited ability and budget to employ additional employees after having made a very substantial financial investment in the software and support services.
The records being handled by these systems contain substantial amounts of text content, most of which will be deemed ‘sensitive personal information’ under GDPR. Much of this content is likely to be added in situations of stress in caring for a patient.
Any failure of the application could have a serious impact on the health of a patient and on the reputation of the hospital, which is subject to external audit by national healthcare agencies. Indeed the priority for clinical staff is to ensure that patients receive the best possible treatment even if that requires a workaround to be used when the application is seen as ‘getting in the way’ of treatment and a full recovery by the patient. This can result in some ethical issues about the extent to which processes can be modified if in the judgment of the individual clinician the modification will result in a better outcome for the patient.
A substantial amount of research has been conducted into the implementation of these systems and on the way in which workarounds emerge and are justified. Clinical staff will be very aware of, and have access to, the research literature, and can use this research to optimise the use of the applications in their own organisation. However, there have been very few research papers in which interviews are undertaken in both business and clinical settings, and even these often do not rigorously compare the outcomes from the two settings.
A bibliometric analysis of research papers on e-health by Gui et al (2019) illustrates well the rapid growth of research from 238 papers in 2007 to 2116 in 2016.
The evolution of these clinical systems was catalysed in the USA by the HITECH Act of 2009. The five HITECH Act goals have been described as the five goals of the US healthcare system – improve quality, safety, and efficiency; engage patients in their care; increase coordination of care; improve the health status of the population; and ensure privacy and security. Elliott (2022) provides a very detailed account of the evolution of these applications. There are differences in the functionality of EHR and EMR (Electronic Medical Record) applications but for the purposes of this book I am focusing on EHR applications. Many of the observations also apply to EMR applications.
An important initiative in assessing the progress of the implication of an EHR application is the HIMSS Electronic Medical Record Adoption Model (EMRAM). EMRAM measures clinical outcomes, patient engagement and clinician use of EMR technology to strengthen organisational performance and health outcomes across patient populations. The internationally applicable EMRAM incorporates methodology and algorithms to score a whole hospital, including inpatient, outpatient and day case services provided on the hospital campus. EMRAM scores hospitals around the world relative to their digital maturity, providing a detailed road map to ease adoption and begin a digital transformation journey towards aspirational outcomes.
The assessment methodology is an element of the Healthcare Information and Management Systems Society (HIMSS) which is a member-based society committed to reforming the global health ecosystem through the power of information and technology. HIMSS has served the global health community for more than 60 years, and has offices in the USA, Germany and Singapore. Its membership comprises nearly 120,000 individuals, 430+ provider organisations, 500+ non-profit partners and 550+ health services organisations.
In the UK the initial focus was on the development of a national Health Record system and indeed when researching EHR activities in the UK using Google it is challenging to distinguish between the national programme managed by the National Health Service and the gradual implementation of EHR applications in hospital trusts (from the mid 2010s) and in general practice.
Another factor that inevitably affects the implementation of EHRs is the attitude and funding of these applications by national healthcare agencies. Although there are many research papers on the implementation of enterprise applications, the research is almost always anonymised. In the case of EHR applications the institution involved is usually clearly denoted and in general there seems to be a wider exchange of experience in the health care sector than in the enterprise sector, driven by the overriding issue of achieving the best possible outcomes for patients.
There are annual HIMSS conferences held in the USA, Europe and Asia-Pacific regions, with the USA event in April 2023 attracting over 1000 exhibitors. Typically, the attendances are of the order of 50,000 delegates. The conference itself offers a very wide range of papers from both software and services vendors and from senior clinicians. Looking through the conference papers for the USA event indicates that there were none that specifically mentioned workarounds.
Kobyashi (2005) reviews the outcomes of earlier research and provides a situational categorisation that probably remains valid today even with a much wider use of EHR applications.
- Dynamic artefacts, such as the large whiteboards used to display OR [Operating Room] status, have been shown to play an important role in the moment-to-moment coordination of medical work by helping workers keep abreast of ongoing exceptions and problems. However, many key artefacts leave no lasting body of knowledge. As a result, there is a lack of organizational memory for workarounds and their effectiveness.
- Despite the omnipresence of cognitive artefacts in the OR, much coordination takes place informally, through conversational and observation, rather than through information systems Charge nurses and anesthesiologists balance the effort required to gather information against the value of accurate information by performing optimal sampling. This suggests that in many cases, workarounds are devised under situations of incomplete information.
- There are limitations in how quickly information is distributed across different hospital locations, even when it is formally embedded in information systems . Again, this suggests that workarounds may be performed without full access to the pertinent information.
- Problems in the specification of workflow patterns and the extent to which workflows can handle exceptions also have implications for the types of workarounds devised by personnel and the success of these workarounds. For example, static assignments of personnel to roles can create problems when extra help is needed in an emergency.
- Observational research on nurses’ problem-solving strategies indicates that in the majority of cases, they deal only with the immediate problem rather than addressing its source. Attempts to alter the system in order to deal with the root cause occur much more rarely. This suggests that medical organisations have problems developing lasting solutions to workflow breakdowns.
As mentioned in Chapter 6 the ability to personalise an application, which is increasingly an important feature of enterprise applications, could be regarded as a workaround in that it is supported by the application. There could be a gap between it being technically possible and being an approved change or enhancement to the process.
HIMSS published a blog post in 2022 on this issue, which is reproduced below in full, which raises the issues around a grey area between workaround and personalised view.
“A common thread for “personalizing the system” is that while there are often tools available to personalize and configure the system, they can be difficult to discover, challenging to scale and share, and overwhelming to interact with in the clinician workflow. If it were simpler to personalize or optimize one’s own EHR experience, there would be little need for an organization to conduct optimization exercises after the initial implementation. After spending eight or more hours in formal training, and then significant time post go-live with practical EHR use, having some simple means available for self-configuration might remove additional hours of optimization, which will in turn reduce physician frustration.
Unfortunately, clinicians often figure out inconsistent “work-arounds” for the original system design as an ad-hoc means of personalisation. Moreover, each EHR update, or “improvement” that is introduced can muddle those personalisations. Updates may then necessitate new workarounds and additional time and cognitive effort to both negotiate the new version, as well as to figure out how to apply prior knowledge to the new system to make it work effectively for the user. By studying these common workarounds, we can identify areas in the system that need design improvements.”
This grey area also complicates process mining as the log data may not show whether or not the employee has used an ‘approved’ personalisation, or a personalisation that they regard as de facto approved just because it can be implemented on the system.
To a greater extent than is the case with ERP applications there is a stronger commitment to identifying how understanding workarounds in the health sector can support innovation in the delivery of health care. Dupret (2018) in particular has focused on the process of innovation. The paper is important in two respects.
The first is that it reviews progress in this area in 2005-2008 and the second is that the examples include studies in geriatric medicine and in psychiatric care. In addition there is a discussion about the way in which health care services are managed and delivered in Denmark which provides important context to the interpretation of the outcomes of the case studies.
Her conclusions was
“Technology workarounds do not necessarily imply technological shortcomings or professional incompetence – quite the opposite. The technology workarounds shown in this paper provide important insights into how health care technologies seem at times to make professionals’ ability to handle the complexity of health care practices invisible. It is not that these technologies in themselves have no important role to play in the sustainability and efficiency of high standard health care, but in some situations, workarounds can consist of new innovative practices that should be acknowledged as such, and they can be a paramount sign of ethically based professional competency and organizational success. Potentially, the critical practice among health care professionals offers crucial insights into health care and creates possibilities for rearranging it through bottom-up processes and the systematic involvement of all stakeholders.”
A notable feature of innovation in this sector is the role that nurses can, and should, play in developing improved and new applications. They are recognised as being core members of a clinical team and may have greater contact with patients than more senior clinical staff, and be directly responsible for the bed-side provision of drugs and other medical interventions.
The largest negative effect was between satisfaction and workarounds of the EHR system to overcome post-adoption dissatisfaction with information quality (Bozan 2018). The research suggests that workarounds are due, to a large extent, to dissatisfaction with the quality of information that the EHR system takes or provides across all four dimensions of information quality. When providers feel dissatisfied with the EHR system’s ability to provide or capture quality information related to patient care, they are more likely to work around the system to capture or acquire the needed information.
In the case of workarounds in general, and in healthcare in particular, the issues of the extent to which the development and adoption of workarounds are ethical is an important topic of conversion. This is a complex area of which I have no direct experience, so I can do no more than point you in the direction of Are workarounds ethical? Managing moral problems in health care systems, authored by Nancy Berlinger (2015). A cursory search of Google Scholar for [workarounds AND ethics] returned a results count of 19,700 for the period from 2019 to the present time.
These references are not just related to the issues of IT workarounds. As an example a paper by Kelly (2022) observes
“Scheduling concurrent procedures is an example of a ‘workaround.’ When complex systems or protocols frustrate actors, some will attempt to circumnavigate the given process by finding a workaround. The complexity of OR allocation and the large number of actors (i.e., administrators, surgeons, anesthesiologists, nurses, staff, etc.) invites workarounds. These solutions may be innovative, yet they represent a source of controversy because workarounds are potentially ethically problematic.
Although they often represent beneficent intentions (e.g., providing prompt care to an individual patient), workarounds can inadvertently introduce unfair bias and unequal distribution of resources. Furthermore, workarounds are construed as rule ‘violations’ in some institutions, which could conceivably contribute to a sense of moral distress and burnout among healthcare providers. Increased awareness and ethical evaluation of the various workarounds that emerge can enhance system learning and potentially improve the allocation process.”
There is probably no better quotation to show that workarounds are indeed here, there and everywhere.
The table below lists research papers and theses which have a substantial critical review of the literature.
The theses by Beerepoot and Elliott are very comprehensive. The thesis by Beerepoot focuses on methods of detecting workarounds in the clinical healthcare sector and the thesis by Elliott examines the flows of information in a clinical (psychiatric) setting.
The bottom line
Many of the issues that arise in a clinical healthcare setting are unique to healthcare but there are also issues that are common to both enterprise and healthcare settings. With a few exceptions (notably the work by Beerepoot) there are very few research projects which compare and contrast workarounds in these two settings. In the next chapter the focus changes to consider the potentially very high risks from workarounds in information-specific applications.
Bade, F.M., Vollenberg, C., Koch, J. Kock, J & Rehse, A.C. (2022). The dark side of process mining. How identifiable are users despite technologically anonymized data? A case study from the health sector. 20th International Conference on Business Process Management (BPM 2022) September 11–16. Lecture Notes in Computer Science 13420, 218-233 https://link.springer.com/chapter/10.1007/978-3-031-16103-2_16
Baillette, P., Barlette, Y. & Berthevas, J-F. (2022). Benefits and risks of shadow IT in health care: a narrative review of the literature. Systemes D’Information and Management, 2, 59-96
Beerepoot, I.M. (2021). Workaround: The path from detection to improvement. (PhD thesis). Utrecht University. https://dspace.library.uu.nl/handle/1874/416626
Beerepoot, I.M. (2021). Workaround: The path from detection to improvement. [PhD thesis, Utrecht University]. https://dspace.library.uu.nl/handle/1874/416626
Berlinger, N. (2015). Are workarounds ethical? Managing moral problems in health care systems. Oxford, Oxford Academic. https://academic.oup.com/book/24742 https://doi.org/10.1093/med/9780190269296.001.0001
Blijleven, V., Koelemeijer, K., Wetzels, M., & Jaspers, M. (2017). Workarounds emerging from electronic health record system usage: Consequences for patient safety, effectiveness of care, and efficiency of care. JMIR Human Factors, 4(4):e27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649044/
Blijleven, V., Koelemeijer, K., & Jaspers, K. (2017). Exploring workarounds related to electronic health record system usage: A study protocol. JMIR Research Protocols 6(4):e72 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5429437/
Blijleven, V., Koelemeijer, K., & Jaspers, M. (2019). SEWA: A framework for sociotechnical analysis of electronic health record system workarounds. International Journal of Medical Information. May; 125:71-78. https://doi.org/10.1016/j.ijmedinf.2019.02.012
Blijleven, V., Hoxha, F., & Jaspers, M. (2022). Workarounds in electronic health record systems and the revised sociotechnical electronic health record workaround analysis framework: scoping review. Journal of Medical Internet Research, Mar 15;24(3):e33046. doi: 10.2196/33046. PMID: 35289752
Bozan, K., & Berger, A. (2018). The effect of unmet expectations of information quality on post-acceptance workarounds among healthcare providers. Hawaii International Conference on System Sciences. https://scholarspace.manoa.hawaii.edu/items/6111d391-33f4-48ed-bccb-b9a47c28ef2d
Dongxiao, G., Tongtong Li, Xiaoyu Wang, Xuejie Yang, & Zhangrui Yu (2019). Visualizing the intellectual structure and evolution of electronic health and telemedicine research. International Journal of Medical Informatics, 130, October, 103947 https://doi.org/10.1016/j.ijmedinf.2019.08.007
Dupret, K., & Friborg, B. (2018). Workarounds in the Danish health sector – from tacit to explicit innovation. Nordic Journal of Working Life Studies, 8, S3. https://tidsskrift.dk/njwls/article/view/105274
Elliott, C. (2022). The preclusive and productive power of information systems: psychiatric clinicians, electronic health records, and the making of health information. (PhD Thesis). University of Syracuse, USA.
Friedman, A., Crosson, J.C., Howard, J., Clark, E.C., Pellerano, M., Karsh, B-T., Crabtree, B., Jaén, C.R., & Cohen, D.J. (2014). A typology of electronic record workarounds in small-to-medium size primary care practices. Journal of the American Medical Informatics Association, 21:e78–e83. https://pubmed.ncbi.nlm.nih.gov/23904322/
Gui, X. et al. (2020). Physician champions’ perspectives and practices on electronic health records implementation: challenges and strategies. JAMIA Open, Jan 7;3(1):53-61. doi: 10.1093/jamiaopen/ooz051
Halbesleben, J.R. (2010). The role of exhaustion and workarounds in predicting occupational injuries: a cross-lagged panel study of health care professionals. Journal of Occupational Health Psychology, 15(1):1-16. doi: 10.1037/a0017634. PMID: 20063955
Huuskonen, S., & Vakkari, P. (2013). “I did it my way”: Social workers as secondary designers of a client information system. Information Processing and Management 49(1), 380-391. https://www.sciencedirect.com/science/article/abs/pii/S0306457312000684
Jylhä, V., Bates, D.W., & Saranto, K. (2016). Adverse events and near misses relating to information management in a hospital. Health Information Management Journal, 45(2) 55–63. https://pubmed.ncbi.nlm.nih.gov/27105482/ DOI: 10.1177/1833358316641551
Kelly, P.D, Fanning, J.B. & Drolet, B.C. (2022). Operating room time as a limited resource: ethical considerations for allocation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190159/
Kobayashi, M., Fussell, S. R., Xiao, Y., & Seagull, F. J. (2005). Work coordination, workflow, and workarounds in a medical context. In CHI EA ’05: CHI ’05 Extended Abstracts on Human Factors in Computing Systems (1561-1564). https://dl.acm.org/doi/10.1145/1056808.1056966 https://doi.org/10.1145/1056808.1056966
Lee, S. & Ji-Soon, K. (2021). Unintended consequences and workarounds of electronic medical record implementation in clinical nursing practice. CIN: Computers, Informatics, Nursing 39(12), 898-907. https://journals.lww.com/cinjournal/Abstract/2021/12000/Unintended_Consequences_and_Workarounds_of.10.aspx
Mörike, F., Spiehl, H. L., & Feufel, M. A. (2022). Workarounds in the shadow system: An ethnographic study of requirements for documentation and cooperation in a clinical advisory center. Human Factors. https://journals.sagepub.com/doi/abs/10.1177/00187208221087013 https://doi.org/10.1177/00187208221087013
Patterson, E.S. (2018). Workarounds to intended use of health information technology: A narrative review of the human factors engineering literature. Human Factors, 60(3),281-292. https://pubmed.ncbi.nlm.nih.gov/29533682/
Persson, J., & Rydenfält, C. (2021). Why are digital health care systems still poorly designed, and why is health care practice not asking for more? Three paths toward a sustainable digital work environment. Journal of Medical Internet Research, 23, 6 e26694. https://pubmed.ncbi.nlm.nih.gov/34156336/
Sheaff, R., Morando, V., Chambers, N., Exworthy, M., Mahon, A., Byng, R. & Mannion, R. (2020). J Health Organ Manag. 34(3): 295–311. doi: 10.1108/JHOM-10-2019-0295
Tucker, A.L., Zheng, S. Gardner, J.W., & Bohn, R.E. (2019). When do workarounds help or hurt patient outcomes? The moderating role of operational failures. Journal of Operations Management 66(4). DOI:10.1002/joom.1015
Van der Waal, W. (2022). WAM! – WorkAround mining in healthcare. BPM’22: International Conference on Business Process Management, September 11–16, Münster, Germany https://ceur-ws.org/Vol-3216/paper_197.pdf
Zhang, Z., Joy, K., Harris, R., & Park, S. (2022). Characteristics and challenges of clinical documentation in self-organized fast-paced medical work. Proceedings of the ACM on Human-Computer Interaction, 6 CSCW2, Article number 386, 1-21. https://doi.org/10.1145/3555111
Zheng K., Ratwani, R.M., & Adler-Milstein J. (2020). Studying workflow and workarounds in electronic health record–supported work to improve health system performance. Annals of Internal Medicine, Jun 2;172(11 Suppl):S116-S122. https://doi.org/10.7326/M19-0871