VA Physicians Continue To Look For EHR WorkaroundsVA Physicians Continue To Look For EHR Workarounds

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Physicians are still using paper-based and electronic "workarounds" with even the most advanced electronic health records, but that is not necessarily a bad thing, research from the U.S. Department of Veterans Affairs suggests. Developers of electronic health records would do well to pay attention to these workarounds as they look to improve their products.

"'Workarounds' has a negative connotation, but to me, it's really a neutral term," Jason Saleem, a research health scientist at the Health Services Research and Development Center of Excellence on Implementing Evidence-Based Practice at the Richard L. Roudebush VA Medical Center in Indianapolis, told information in an interview. "But a lot of these are really positive."

Saleem and colleagues at the Indianapolis VA published a study in the July issue of the International Journal of Medical Informatics that illustrates how paper processes often get added during consultations between primary care physicians and specialists. For example, many doctors would prefer to print out copies of records rather than view information on a computer screen, or simply jot down notes as memory aids. And some physicians like to create electronic spreadsheets to track the status of referrals, the researchers reported.

In all, they found 11 different categories of workarounds. The researchers studied five years of records from nine different specialty clinics and three primary care clinics affiliated with the Indianapolis VA. "We identified several examples of paper persistence, as well as workarounds, communication breakdowns, and redundancies in computerized consult management. An analysis of enhancement requests for the consults also revealed three broad needs related to reporting, configuration or customization, and user interface enhancements," the study said.

"Some of these [extra processes] are really important because they offer efficiencies," Saleem explained. They also could help with coordination of care.

"Although some of the paper-based workarounds revealed are problematic, others offer efficiencies and other advantages over corresponding electronic workows and disclose potential limitations of the design of the computerized systems," according to the study.

"Understanding these challenges to the current consult management process is important to help design enhanced informatics tools integrated into workflow to support coordination of care and tracking of consults requests."

Because the study took place at the VA, all the records were stored in the Veterans Health Information Systems and Technology Architecture (VistA) system, one of the most widely used and well-developed EHRs in the world.

"That's the best place to study these problems because [it shows that] we still have a long way to go," Saleem said. "I'm shining a light on different problems with electronic health records," he added.

Indeed, the new paper is a follow-up to a 2009 pilot study in the same journal about the continuing reliance of paper, even in facilities that have long had EHRs. That pilot led to Saleem gaining a five-year VA career-development award to expand the research. This research on workarounds represents the first year of work on that grant.

Saleem expressed hope that other organizations and EHR developers can learn from his ongoing research to improve clinical information systems.

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