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TRANSCRIPT
Workarounds to hospital electronic prescribing systems: a qualitative
study in English hospitals
Keywords: health information technology, implementation, adoption, ePrescribing
Word count: 3722
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Abstract
Background: Concerns with the usability of electronic prescribing (ePrescribing) systems can lead to
the development of workarounds by users.
Objectives: To investigate the types of workarounds users employed, the underlying reasons
offered, and implications for care provision and patient safety.
Methods: We collected a large qualitative dataset, comprising of interviews, observations and
project documents, as part of an evaluation of ePrescribing systems in five English hospitals, which
we conceptualised as case studies. Data were collected at up to three different time points
throughout implementation and adoption. Thematic analysis involving deductive and inductive
approaches was facilitated by NVivo 10.
Results: Our dataset consisted of 173 interviews, 24 rounds of observation and 17 documents.
Participating hospitals were at various stages of implementing a range of systems with differing
functionalities. We identified two types of workarounds: informal and formal. The former were
informal practices employed by users not approved by management, which were introduced
because of perceived changes to professional roles, issues with system usability and performance,
and challenges relating to the inaccessibility of hardware. The latter were formalised practices that
were promoted by management and occurred when systems posed threats to patient safety and
organisational functioning. Both types of workarounds involved using paper and other software
systems as intermediaries, which often created new risks relating to a lack of efficient transfer of
real-time information between different users.
Conclusions: Assessing formal and informal workarounds employed by users should be part of
routine organisational implementation strategies of major health information technology initiatives.
Workarounds can create new risks, but also present new opportunities for improvement in system
design and integration.
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BackgroundHospital electronic prescribing (ePrescribing) systems offer considerable potential to improving the
quality, safety and efficiency of care.[1,2] However, they are not yet part and parcel of everyday
healthcare delivery in most United Kingdom (UK) hospitals.
New practices of delivering care and organising healthcare professional work associated with health
information technology (HIT) introduction, mean that users need to change existing practices to suit
the digital environment.[3-5] Workarounds are behavioural/technological strategies that users of
technology employ to deal with perceived problems that hinder them in achieving their goal.[6,7]
They often arise in the context of changed workflows brought about by the new technologies.[7,8]
Workarounds have commonly been viewed as negative in discussions on HIT, as the resulting
changes to working practices can pose significant risks to patient safety and organisational
functioning.[9-11] For example, Koppel and colleagues assessed workarounds in a barcode
medication administration system and found that these resulted in a range of adverse consequences
including administration of inappropriate medicines, unsuitable doses, and incorrect times.[12]
Some have suggested that workarounds can also wrongly convey that solutions to existing systems
problems have been found and that managerial interventions are not required.[11] However, the
prevalence of informal workarounds may reflect weaknesses in organisational learning mechanisms
insofar as local problem solving by individuals and groups is not used as a resource to develop robust
well-functioning systems, which is a defining characteristic of high reliability organisations.[13-18]
Being aware of workarounds and associated possible adverse consequences can help to mitigate
risks by effectively re-designing existing workflows and/or technological systems. Conversely,
although workarounds are often seen as disruptive and unintended from managerial perspectives as
they can reduce the amount of organisational control over practices on the ground,[19] they can
also be adaptive, particularly when exploiting the innovative capacity of system users and also
potentially identifying opportunities to enhance system design and work processes. In this capacity,
they can also allow users to mitigate perceived risks to patient safety posed by HITs – for instance,
when a system is not well designed and/or suited to the environment in which it is being deployed.
[19,20] They may also be able to help to identify inappropriate policies or business process changes
surrounding HIT that may interrupt the delivery of day-to-day care.[21,22] They can also serve as
intentional organisational strategies to help users engage with new systems for example by
maximising benefits and minimising disruption to existing procedures.[23]
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The lack of existing empirical work and theorising surrounding workarounds in healthcare has
repeatedly been emphasised.[7,24] In particular, there is a need for better conceptual models of the
reasons underpinning workarounds.[24] To contribute to this evidence base, we examined
workarounds as part of a large national evaluation of ePrescribing systems in English hospitals.[4]
The aims of this work were threefold, namely to investigate: 1) what workarounds were employed
by users of ePrescribing systems; 2) why these were undertaken; and 3) how workarounds could
create and mitigate risks associated with the implementation and adoption of hospital ePrescribing
systems.
Methods
This work drew on a large dataset we have amassed in recent years undertaking a series of
longitudinal, multi-site, qualitative case studies of commercially available ePrescribing systems in
English hospitals. Previous publications from this dataset have related to product diversity and
markets,[25,26] procurement,[27-29] integration and interfacing,[30] user engagement,[31]
implementation processes,[3,32] and patient and vendor perspectives.[33,34] The avenues of
investigation emerged from the existing literature, initial themes inductively identified from early
results across sites, and our own experience from related evaluations of large-scale HIT initiatives.[5]
Participating hospitals were treated as individual cases.[35]
Approvals and permissions
We received Institutional Review Board approval from The University of Edinburgh, UK. An
application was reviewed by a National Health Service (NHS) Research Ethics Committee that classed
the work as a service evaluation. All necessary regulatory approvals were obtained from case study
sites and individuals gave written informed consent to participate. All names and places were
anonymised by the authors in order to protect the anonymity.
Sampling
Our purposeful sampling strategy aimed to identify English hospitals that had implemented, were in
the process of implementing, or were planning to implement ePrescribing systems during the
conduct of the research (a period of five years).[36] Prior to implementation of ePrescribing, sites
were using paper drug charts that nurses used to administer medication. As there were a limited
number of hospitals with ePrescribing systems when our work commenced in 2011, we sampled
those hospitals that were planning implementation of systems soonest. Organisations varied in
demographic characteristics (urban/rural, teaching/non-teaching), type of system (standalone
ePrescribing functionality versus as part of an integrated system), and time since implementation
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began (or was about to begin) (see Table 1). Our initial point of contact was the Director of
Pharmacy or equivalent.[37]
Within hospitals, we sampled a range of managers (information technology and clinical
implementation team members) who were, or were to be, involved in implementing ePrescribing
systems. We then snowball sampled a range of users from these contacts including doctors, nurses,
pharmacists, allied health professionals, and pharmacy technicians. These varied in levels of
seniority and experience with ePrescribing system use.
Data collection
Methods of data collection included a mixture of interviews, non-participant observations, and
gathering of documents. This range of data sources permitted us to gain insights into individual
expectations and experiences (interviews), changes to work and organisational practices brought
about by the implementation (observations), and organisational implementation plans and
procedures (documents) (see Table 2).[38] Interviews were the main source of data and these were
conducted by experienced qualitative researchers (KC, HM, LL) at up to three different time points
(see Table 2). This longitudinal dimension allowed us to track changes over time and helped to
assess temporary and longer-term difficulties encountered as well as strategies employed to address
these.[39] Interviews were tailored to individual sites, professions and backgrounds, but generally
explored topics surrounding experiences and expectations, perceived changes to work practices and
organisational functioning, and barriers/facilitators to implementation and adoption.
We also wrote field notes of non-participant observations. These included following individual
system users throughout their normal working day and observing how they used the system.
Observations also involved attending strategic meetings in order to gain insights into organisational
dimensions of implementation strategies.
Organisational documents collected, consisted of business cases, implementation plans, work
practice maps, risk registers, and lessons learnt reports. These provided insight into the practices
that were perceived as compromising patient safety.
Interview data were digitally audio-recorded and transcribed verbatim. Data from all sources were
uploaded onto NVivo 10.[40]
Data analysis
We employed a mixture of inductive and deductive analysis. Data were analysed within cases first,
followed by cross-case analysis. Initially, the lead researchers (KC, HM, LL) coded individual case
study data, drawing on a system lifecycle model developed as a coding framework (the deductive
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component).[41] This helped to conceptualise the implementation and adoption journey
surrounding ePrescribing technology and included temporal stages from initial conception, through
implementation, to system optimisation. During this process, we also noted emerging themes that
were not captured in our code book, but which occurred frequently across data sources and
individual participants (the inductive component).
Data across sites were then examined in designated data analysis meetings, where we drew on the
Theory of Workarounds as an analytical lens.[6] The Theory of Workarounds is concerned with
different types of workarounds, attempting to explain why they occur, and describing their
consequences. It suggests that workarounds emerge, based on situational characteristics and the
goals and needs of different stakeholders. The decision as to whether to employ a workaround is
assumed to be based on perceived benefits, risks and costs. The framework therefore offered an
appropriate lens to examine emerging issues across sites and contributed to a nuanced analysis of
emerging issues from a range of different perspectives.
The credibility of findings was enhanced through triangulating data sources obtained through a
range of methods, keeping reflexive field journals to record any potential researcher bias, and
through active involvement of the extended research team in the analysis. This included examining
codes and discussing negative cases.
Results
We conducted 173 interviews, 24 observations and collected 17 documents between December
2011 and March 2015 (see Table 2).
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We identified different types of workarounds employed by users of the new technology. These often
involved using paper and other technologies for intermediary storage of information (see Table 3).
Workarounds were most commonly associated with perceived limitations in system design,
potentially leading to patient safety risks. Our inductive analysis indicated that they could be divided
into ad-hoc workarounds, which were conceptualised as informal practices employed by users that
were not approved by management (including the implementation team and senior clinical
managers), and formalised workarounds, which were conceptualised as necessities that were
accepted and sometimes actively promoted by management. An overall graphical presentation of
our findings is given in Figure 1.
Reasons for employing workarounds
Contingent nature of healthcare professional work practices and lack of system flexibility The main underlying reason for adopting workarounds appeared to be the extraordinary complexity
and variability of healthcare workflows, which were not well catered for in existing system designs.
As a result, users had to “find shortcuts” (Site D, Pharmacy Technician, T3) or “find ways around”
(Site E, Nurse, T2) the way the system defined their workflows. The limited capacity of systems to
cater for a diversity of practices (e.g. through libraries of pre-programmed options that could be
locally configured without rewriting code) was seen as a consequence of these being relatively
immature solutions. This was an issue both in relation to stand-alone systems and integrated
systems. In addition, information displays often failed to address the exigencies of particular
moments of healthcare work, necessitating for example a cumbersome switching between screens.
… at the moment [warfarin and International Normalised Ratio (INR)] run two different screens kind
of within the system so [users] need to go and look at what the recent INR’s are, go into the drug
chart and see what the doses of warfarin have been and go to a different screen to prescribe and
that just isn’t a tidy way to work. (Site D, Implementation Team, T2)
Compensating for the increase in workloads associated with use of the system
Another underlying reason for employing workarounds was the perceived necessity to compensate
for the increased time it took to use the systems. Here we found that workarounds helped users to
accommodate the increased time required to perform tasks.
Everything is taking us a lot longer to do…and that’s why we’re trying to find ways around and just
streamlining the process for us so that we can do as much as we can. (Site D, Pharmacy Technician,
T2)
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In stand-alone systems pharmacists, for instance, would verify orders in batches, as doing each order
separately was perceived to take too long, finding a time and perhaps a quiet place (not in the
dispensary) where they would not be interrupted.
…we now do like [system] slots where we have to sit and verify the prescription separately in the
dispensary because it takes a lot longer to do and needs more concentration than what you would
get in the dispensary… by the time you’ve checked the bloods, checked the other [paper patient
notes], converted it, rang the doctor, gone back to it, you need to do that without being constantly
interrupted like you would be in the dispensary. (Site D, Pharmacist, T1)
Changes to professional roles and responsibilities resulting from system design
Workarounds were also employed to mitigate perceived changes to professional roles and
responsibilities. For instance, consultants in many cases delegated use of the system to their juniors:
I think there are some consultants who still sort of need their inbox to be managed by their secretary
… And then when it comes to them doing the ward rounds, they would tell the juniors what to
prescribe and what to do so they aren’t very hands-on… (Site D, Pharmacist, T1)
Types of workarounds employed
Using other systems as intermediary storage of informationWe frequently observed users drawing on other electronic systems as intermediary storage of
information. This kind of workarounds was more common with stand-alone systems (i.e. those that
were not designed to integrate with medical notes), and included for instance using Microsoft Word
to store temporarily text that needed to be transferred from the Patient Administration System.
It’s just a [Microsoft] Word document that we cut and paste in, that we save on our desktops… (Site
C, Pharmacist, T3)
Emails were also used intermediaries. For example, a workaround employed by pharmacists related
to requesting medication. As each requested medication from a nurse resulted in a printed request
form in the dispensary (this process was not fully electronic due to limited functionality being
deployed at the time), pharmacists designed a workaround that would allow nurses to request items
through informal means (an email) which were then translated by pharmacists into a formal
inpatient order on the ePrescribing system. However, this workaround was subsequently abandoned
due to potential legal issues and increased workloads.
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…the nurses were basically sending us an electronic message to say “please can you supply these four
items”… and then someone in pharmacy was translating that onto the inpatient order and printing
off one piece of paper requesting those four items. (Site D, Pharmacist, T2)
Similarly, paper was often used as an intermediary means to store information in instances where
users did not have easy access to electronic means or were too busy to transfer information
electronically. Paper was also utilised when users wanted to memorise something that needed to be
transferred from one screen and to another (store and transmit).
The pharmacist goes back to the computer and puts a note onto a medication on [system]. He then
takes a piece of paper and writes on it that he has left a note on [system] and where. He writes
“[name of person] please” on it and states that “this is how I tend to communicate with doctors”.
This is funny – he is writing a paper note to remind doctors to look at an electronic note! (Site A,
Pharmacist, Observation, T1)
Other types of workarounds observed included entering information in batches to save time, and
ticking boxes in order to satisfy the demands of the system (see Table 3).[20,42,43]
Consequences resulting from workarounds: the introduction of new risksWorkarounds sometimes created new risks, such as delayed access to information or difficulty
finding information for other professions. This was the case, for instance, when users did not follow
the process dictated by the system in the right order. Here, doctors sometimes prematurely ticked a
box in the system and then subsequently changed their mind, which was then not reflected in the
system.
…if you do the histories first, it’s very quick, if you don’t, you’ve got to put each one in and then it
doesn’t then come right into the discharge letter so the process is really important but I can’t make
people do it, the system doesn’t make you do it right. (Site D, Consultant, T2)
Similarly, some systems required users to refresh the screen to look at the most recent version of
the medication chart. The need to manually refresh the screen meant that the information displayed
might not be up to date and this could create the scope for errors.
I’d like to do away with the concept that you have to refresh a drug chart I think that’s really, really
dangerous because obviously you can train people as much as possible to say refresh it before you do
anything but it’s still an obvious banana skin lying around just for someone to slip over. (Site D, Junior
Doctor, T2)
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In some cases, shortcuts resulted in other healthcare professionals not finding the necessary
information on the computer system. For example, in one hospital, we learned that nurses would
tick a box in the system that stated “drug not administered” (even though the medication was
administered but not in line with the timing schedule of the system) as this was seen as the only way
to complete a routine on the screen. When prompted for a reason by the system, then they would
tick another box stating “see notes” to avoid having to complete what they perceived to be
cumbersome patient records in the system. No note was however added. This presented issues for
the pharmacist reviewing the medications who could then not find out why a medication had not
been given.
…what you find is that [nurses] tend to tick any old box that doesn’t necessarily relate to why the
patient hasn’t been given the drug, so the concern is that the common one that they tick is “see
notes” and then there’s no note generated to say why the drug wasn’t given. (Site A, Pharmacist, T1)
Managers stated that appropriate training could to some degree minimize workarounds that were
viewed as unnecessary.
I can’t impose any workaround I have to work within the parameters of the system and it’s about
identifying what the issues are and just maybe training people the best way to use the system. (Site
C, Pharmacists, T3)
Formalising strategies: management efforts to mitigate risks associated with
workarounds
We also identified formalised workarounds that were seen as necessary by the organisation to
maintain organisational functioning and patient safety while using an “imperfect” technical system
These might arise because of a lack of integration in stand-alone systems, where limited
functionality had been implemented in early integrated system implementations, where there were
usability problems, or where adopter organisation practices diverged from those embedded in the
software package. They were therefore promoted by management, shared across specialties, and
expected of users.
We still have frustrations around the basic software itself…but quite often we can develop
workarounds… (Site A, Implementation Team, T2)
These formalised workarounds were promoted when persistent problems in technical design
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threatened patient safety (as opposed to issues associated with increased workloads and changing
roles of staff). Some were designed to facilitate more efficient information transfer. For instance,
when creating discharge medications on the ward, the system would not automatically alert the
pharmacists to initiate the dispensing of discharge medications. Therefore, doctors on the ward and
pharmacists agreed that a “fake drug” would be created in the system in order to alert pharmacists
that discharge medications were needed.
Now what they [doctors] do is they, on the inpatient order on the screen, they right click “convert to
prescription”, and they end it with a discharge medication list that they've created from the inpatient
list. Which is obviously just the things they need the patient to go home on, with appropriate course
lengths for antibiotics and stuff like that. But there's no way for pharmacy to identify that that's been
done. So the way we got around that is we created a fake drug called “TTO [To Take Out] for
discharge” so the doctor would complete all the medicines and then prescribe TTO for discharge
which appears on the inpatient order. (Site D, Pharmacist, T1)
Similarly, if prescribers wanted to use specific medicines that were not held in the system, then
workarounds drawing on paper systems were created to compensate for this.
They are things that we can’t do, you know, for example if a prescriber wants to prescribe and it’s not
on the system then the workaround this is to put in a generic drug and then we write in a note about
what the drug is… (Site C, Pharmacist, T3)
In other instances, the system made actions “too easy” for users. This was the case when nurses
ordered medication at the click of a button, without checking which medicines had already been
ordered as this would involve navigating to another screen. The increased ease of ordering resulted
in a greater number of inappropriate and duplicate orders which pharmacists had to verify. As this
was viewed as a time consuming activity in the ePrescribing system, management created a
workaround that allowed nurses to order medications in batches by email.
If an order is created using the system then it still needs somebody to go through and cross off the
things that aren’t needed and we’ve created a system whereby nurses can identify electronically that
they wanted something and send an email saying “we want this, this and this” which obviously we
can look at on the electronic system but we just found it loads of duplication, it was too easy to order.
(Site C, Pharmacist, T3)
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Temporality of workaroundsImproving patient safety was an important motivator for management to help users compensate for
known technical limitations by mitigating known risks associated with the system. Many of these
were temporary and associated with the gradual adoption and implementation of the system, which
necessitated some degree of parallel paper and electronic means being used alongside each other.
This was perceived to create risks of error.
A&E [Accident and Emergency] our emergency department still don’t use [system]…they still write
doses of medications on their casualty sheet, on paper…and we have had incidents where something
is prescribed in A&E on paper, the nurses and medics don’t realise and they get a second dose within
a short time for example. (Site A, Consultant, T1)
In some instances, workarounds were also found to provide a quicker way for organisations to
resolve the gap between local working practices and standardised ePrescribing packages than
seeking to modify or customise the package.
Yes so it’s not how [system supplier] envisage it being used, it’s how we are then adapting the system
to give it things that we want. And what you’ll find is that we’ll all do that in a slightly different way…
because we’ve worked a workaround round. (Site C, Pharmacist, T1)
However, finding appropriate workarounds proved difficult or even impossible in some instances
where efficient organisational functioning was threatened. In these instances, where workarounds
could not be found, hospitals argued for the need to change the technical system.
… a workaround was brought up which was declined for governance reasons…it actually created a
complete new level of work to be done (Site E, Implementation Team, T2)
Discussion
Workarounds arise from the strategies employed by individuals or groups of users of HIT to mitigate
perceived barriers to completing tasks. They can also become incorporated as part of organisational
mandates to mitigate risks to patient safety brought about perceived shortcomings in the usability of
new systems. We have found that, on occasions, these workarounds created new often
unanticipated and unintended risks to patient safety.
The motivations to introduce workarounds were mainly associated with concerns surrounding poor
usability, but in line with other work in the area, we also observed other motives for example where
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personal values were threatened or where systems did not align with professional norms or broader
conditions (e.g. time pressures).[18,44-46] Although some types of workarounds observed here are
consistent with previous research, particularly in relation to the use of paper and other software
systems as intermediaries (Table 3),[20,42,43] and dealing with perceived system limitations,
obstacles to work routines, threats to time and pretending compliance;[18,47-52] we also found
some strategies employed by users that involved delegating input of electronic information and
compromising the temporal accuracy of electronic systems by deferring information input.
The distinction between informal and formalised workarounds can be particularly helpful in
promoting organisational learning, cooperative working and promoting patient safety.[13-18] It
builds on the notion that workarounds can be used as intentional organisational strategies to help
users gradually get used to new systems.[5,23] Problems may arise if these are not addressed in a
pro-active manner to create more robust and well-considered solutions. If, for instance, consultants
keep delegating data input to juniors (something than can be seen as first-order problem solving),
then this staff group may become increasingly overloaded. If management is not aware of this, then
appropriate interventions such as, for example, the employment of data entry clerks, are unlikely to
be implemented in time. If, workarounds are formalised then it is easier to track and anticipate
emerging issues and embark upon mitigating action to address emerging systemic issues. This
suggests that workarounds only become a threat to organisational functioning if they are not
formalised. The question is when and what to formalise and this could be a fruitful area of future
work in this area.
The frequent use of paper and other software systems as intermediaries in both standalone and
integrated systems, may suggest a lack of system integration in the ePrescribing solutions we
studied. They may therefore present temporary workarounds that may attenuate as increasing
system functionality is implemented and systems are progressively integrated.[52]
Workarounds can both introduce new risks to safety (most commonly associated with a lack of up-
to-date clinical information) and mitigate risks resulting from poor functionality and/or usability. As
they often involve innovative user behaviours, they may therefore also be used as a source of design
enhancements.[20] However, it is also important to keep in mind that workarounds can change over
time and may become inter-dependent with each other. They may also be seen as
organisational/user ways to tailor systems to contexts of use and thereby impact on system
standardisation, as well as system maintenance and upgrades. As such, they may be conceptualised
as part of the tacit skills and cooperative activities through which work is accomplished as an
everyday, practical activity.[53,54] This suggests that rather than trying to demonise these kinds of
13
informal practices, they should be made visible as they may be needed to “get a job done”. In doing
so, it is important to keep in mind that different viewpoints are at play and views on which action
needs to be completed often vary widely across organisational stakeholders.
It is therefore important to track how formal and informal workarounds are operationalised over
time. Management tools incorporating such assessments exist and studying their routine use in
healthcare settings is an important area for future work. For example, the Workaround Design
System is a tool that can help to anticipate and address undesired workarounds.[55] Similarly, the
Workaround Process Modeling Notation incorporates workarounds into business process modelling,
thereby helping to anticipate how changes to workflows are likely to be dealt with by users.[56]
However, such tools place the onus of modelling and design on managers, which may lead to
inadequate reflection on informal practices. They also rely on the willingness/ability of developers to
change systems accordingly, which is not always possible in large-scale commercial systems. In
addition they do not address issues surrounding the de-activation of workarounds once new
functionalities are introduced.
We have collected a sizeable longitudinal qualitative dataset drawing on a variety of perspectives
and data sources. Although this work has provided some important insights into the under-theorised
area of workarounds and their consequences in HIT, there are also a number of limitations. Firstly,
informal workarounds are hard to research and observe – particularly those that are undesired by
management. As a result, we expect that users may not have reported/exhibited many informal
workarounds. Secondly, workarounds can be subjective and hard to define. What constitutes a
workaround from a managerial perspective may not necessarily be perceived as such from a user
perspective and vice versa. Similarly, healthcare professions may view workarounds differently.
Thirdly, some of the systems implemented in each hospital were originally designed for use in
countries other than the UK. This may have resulted in more workarounds used due to international
differences in workflows. In addition, we did not gain insights into the nature of workarounds
employed with paper systems, so we did not obtain any insights in relation to the nature of
workarounds existing with these and how they changed with the introduction of the system.
Conclusions
This work has helped to provide insights into the way users and organisations have coped with the
perceived limitations in functionality and usability of existing ePrescribing systems being deployed in
English hospitals. Issues with information integration in particular seem to have contributed to a
range of workarounds designed to bridge informational gaps. This highlights that rule-based
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accounts of organisational activities need to move away from viewing workarounds as a risk towards
viewing them as a necessity
The differentiation between informal and formal workarounds now needs to be taken forward in
existing management tools designed to anticipate risks and opportunities created through
workarounds employed by users. Essential to this will need to be recognition that informal
workarounds may require system re-design and/or need to be formalised in order to better
anticipate potentially adverse consequences.
15
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20
Figures and tables
Table 1: Characteristics of case study hospitals
Hospital identifier and
characteristics
Implemented system Timeframe of
implementation
Site A: urban, acute care Commercial ePrescribing system
ePrescribing not part of a wider hospital-wide
information system
Began implementation
in 2010
Site B: rural, acute care,
teaching
Commercial ePrescribing system
ePrescribing as part of an integrated hospital
information system
Began implementation
in 2009
Site C: urban, acute care,
teaching hospital
Commercial ePrescribing system
ePrescribing as a standalone application
Interfaces built to enable interoperability with the
wider hospital information systems
Began implementation
in 2013
Site D:
urban, acute care, teaching
Commercial ePrescribing system
ePrescribing as part of an integrated hospital
information system
Began implementation
in 2014
Site E: urban, acute care,
teaching
Commercial ePrescribing system
ePrescribing as part of an integrated hospital
information system
Began implementation
in 2014
Table 2: Summary of the dataset
Hospita
l
Interviews Documents Observations Data collection period
Site A Time 1 (T1):
23
Time 2 (T2):
eight
Eight
documents
Eight observations (12.5
hours)
Notes from recruitment
meeting
T1, after implementation: December
2011 - August 2012
T2, after implementation: January
2014 - February 2015
21
Site B T1: 20
T2: 11
Three
documents
Four observations (nine
hours)
Notes from recruitment
meeting
T1, after implementation: May 2012 –
June 2013
T2, after implementation: December
2014 - March 2015
Site C T1: 13
T2: 18
T3: 20
Nine observations (11
hours)
T1, before implementation: May –
August 2012
T2, after implementation: May – July
2013
T3, after implementation: August -
November 2014
Site D T1: 15
T2: 14
Two
documents
Notes from recruitment
meeting
T1, before implementation: July-
October 2013
T2, after implementation: June-July
2014
Site E T1: 23
T2: 17
Three observations
Notes from recruitment
meetings
T1, before implementation: April-July
2013
T2, after implementation: November
14 - March 15
Table 3: Types of workarounds identified and how these align with the current literature
Workarounds observed Workarounds identified in the literature
[20,44,45]
As a result of the cumbersome switching
between screens and a lack of information
integration between systems, users in some
instances used other programs such as Microsoft
Efficiency (when paper or other software was
perceived to improve efficiency)
22
Word as intermediary storage of information.
Due to the perceived necessity to compensate
for the increased time it took to use the system,
we found that users drew on paper and other
software systems to accommodate the increased
time required to perform tasks.
Knowledge/skill/ease of use (when paper or
other software use was perceived to be easier)
Paper was often used as an intermediary storage
of information e.g. to remind doctors to look
something up on the system.
Memory (using paper or other software as a
reminder)
“Tricking the system” (e.g. inserting inaccurate
or incomplete information to be able to click
through screens, temporary data, insertion of
pre-defined terms).
“No correct path” (can consist of ticking an
option that is incorrect to be able to move on in
the system, gaming to satisfy system demands,
using incorrect electronic documentation to
reflect paper-based plan)
Not observed Sensorimotor preferences (paper preferred as it
is more tangible)
Not observed Awareness (paper or other software can serve to
more effectively draw attention to information)
Paper was often used as an intermediary means
to store information in instances where users did
not have easy access to electronic means or
were too busy to transfer information
electronically. Paper was also utilised when users
wanted to memorise something that needed to
be transferred from one screen and to another
(store and transmit).
Task specificity (using paper as it can fulfil certain
needs for tasks better than the system)
If prescribers wanted to use specific medicines
that were not held in the system, then
workarounds drawing on paper systems were
created to compensate for this
Task complexity (EHR present problems to
workflow so paper preferred)
Cumbersome switching between screens
necessitated users to find shortcuts.
Data organization (difficult to view data in
desired format in EHR so drawing on paper or
other software)
Not observed Longitudinal data processes (user needs quick
23
and repeated data recording/processing)
Not observed Trust (in paper when compared to EHR)
Not observed Security (perceptions around EHR security and
view that paper is safer)
Delegating input of electronic information Not observed
Deferring input of electronic information Not observed
Entering electronic information in batches Not observed
Using electronic shortcuts to save time Not observed
Cross-referencing to paper notes Not observed
24
Figure 1 – Illustration of different types of workarounds observed and associated consequences
25
Informal workaround Formal workaround
New risks relating to information transfer
Time pressure
Changes to professional
roles
Issues with system usability
Challenges surrounding
hardware and space
Paper and other software systems used as intermediaries
Issues with
system usability
Threats to
organisational
functioning
New opportunities for benefits/rethinking processes