Workaround

In clinical information systems, workflow is defined as “the set of tasks—grouped chronologically into processes - and the set of people or resources needed for those tasks that are necessary to accomplish a given goal.”6 A workaround is a behavior undertaken to circumvent an expected or designed workflow, which can be undertaken for several reasons, but are associated with unintended consequences which can bring about safety concerns in a clinical setting. “Workarounds circumvent or temporarily ‘fix’ perceived workflow hindrances to meet a goal or to achieve it more readily”3. Some workarounds are created to enhance efficiency in a suboptimal workflow, while others can be brought about by intentional blocks created by electronic health records or within processes designed to ensure safety procedures are undertaken. Attributes of EHR workarounds include:

(1) a conflict of goals that need to be addressed in pursuing work practices;

(2) a workflow bottleneck that needs to be overcome to carry out a task;

(3) the opportunity to conceive a workaround;

(4) the assimilation of humans and technology.2

These attributes exclude circumstantial deviations that are made in response to temporary changes to the system. The usage of workarounds exist in many industries, and studies have shown that this is occurring in all clinicians, with a majority of workarounds coming from physicians.

Identified rationales

There have been some studies which have elicited end users’ understanding of workarounds, and their rationales for employing them. Some of these are knowledge based, whether it be declarative or procedural knowledge of the workflow. These can be addressed with increased clinician training and education. Technical limitations related to the usability of the EHR system, technical processes of the EHR, and patient data presentation or specificity are other concerns which can be targets for further study in informatics. There have also been clinicians who explained their rationale as a “commitment to patient interaction”, which is related to clinicians not employing EHR as intended due to concerns with the data entry interfering with other clinical responsibilities including patient interaction.2 These rationales vary greatly, but do highlight the need for alignment between those creating workflows in an electronic health record and the clinical end users to properly mirror system design with actual practice.

Consequences

Workarounds present opportunities for clinicians to deviate from expected behaviors, which can lead to adverse patient outcomes and decreased healthcare quality1. While there are significant opportunities to harm patients, there are some perceived beneficial consequences to clinicians, who find that workarounds can be employed to increased efficiency5. There are also instances where the culture of an institution has led to the propagation of the workaround as the accepted workflow.2

Current literature

Workflows and workarounds are easily understood phenomena, but have been hard to quantify in studies. Data sources and methodologies to study workarounds vary greatly, and as such require further research. Typically, workarounds are studied by direct observation, or by studying metrics within electronic health records. Protocols exist for workaround studies, but further validation is required. Workarounds are integral to understand how to optimize the design of clinical information systems and fit into a larger picture of understanding usability of electronic health records.

References

1. Blijleven V, Koelemeijer K, Wetzels M, Jaspers M. Workarounds Emerging From Electronic Health Record System Usage: Consequences for Patient Safety, Effectiveness of Care, and Efficiency of Care. JMIR Hum Factors. 2017;4(4):e27. Published 2017 Oct 5. doi:10.2196/humanfactors.7978

2. Boonstra, A., Jonker, T.L., van Offenbeek, M.A.G. et al. Persisting workarounds in Electronic Health Record System use: types, risks and benefits. BMC Med Inform Decis Mak 21, 183 (2021). https://doi.org/10.1186/s12911-021-01548-0

3. Debono DS, Greenfield D, Travaglia JF, et al. Nurses' workarounds in acute healthcare settings: a scoping review. BMC Health Serv Res. 2013;13:175. Published 2013 May 11. doi:10.1186/1472-6963-13-175

4. Mula CT, Human N, Middleton L. An exploration of workarounds and their perceived impact on antibiotic stewardship in the adult medical wards of a referral hospital in Malawi: a qualitative study. BMC Health Serv Res. 2019 Jan 23;19(1):64. doi: 10.1186/s12913-019-3900-0. PMID: 30674316; PMCID: PMC6345002.

5. Ross Koppel, PhD, Tosha Wetterneck, MD, MS, Joel Leon Telles, PhD, Ben-Tzion Karsh, PhD, Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety, Journal of the American Medical Informatics Association, Volume 15, Issue 4, July 2008, Pages 408–423, https://doi.org/10.1197/jamia.M2616

6. Zheng K, Ratwani RM, Adler-Milstein J. Studying Workflow and Workarounds in Electronic Health Record-Supported Work to Improve Health System Performance. Ann Intern Med. 2020 Jun 2;172(11 Suppl):S116-S122. doi: 10.7326/M19-0871. PMID: 32479181; PMCID: PMC8061456.

Submitted by Sunil Seoparson