4. Results
5.2 Research question 2: How Does the Sociotechnical Context Influence the Workflow
Use of Patient-Reported Information?
In this section we describe how the sociotechnical context influences the workflow related to patient-reported information. The sociotechnical contexts consist of five elements: the
environment, the organization, the tools and technology, the person, and the tasks (see Figure 1, the SEIPS model).
Several factors in the sociotechnical context influence workflow related to patient-reported information. Five of the six clinics in our study use secure messaging, and by comparing the clinics, we can draw some conclusions about the influence of the sociotechnical context. For the other two health IT applications, we do not have enough data to assess the impact of the
sociotechnical context.
Results of our analyses show more similarities than differences in the workflows in the facilitators and barriers to secure messaging across clinics. This finding suggests that, overall, the facilitators and barriers are the result of the health IT application regardless of the sociotechnical context. Four of five clinics use very similar patient portals, from the same vendor, through which patients can send secure messages, and the facilitators and barriers to secure messaging may also reflect the specifics of this portal system. However, it is difficult to draw conclusions on this point, because the only clinic that uses a different health IT vendor also has other characteristics that are different: it is a solo physician practice with a different workflow than the other four larger clinics. Nevertheless we identified some differences between clinics that were related to technological organizational and personal aspects of the sociotechnical context.
For clinics the length of time since health IT implementation has an important impact on workflow. The literature shows that patient uptake of patient portals is slow;12,13 it takes time for patients to sign up for a clinic’s patient portal and even more time before patients actively start using health IT applications in the portal, for example sending secure messages to the clinic. Clinics that only recently implemented a patient portal have fewer patients signed up or actively using the applications, and therefore a lower volume of secure messages. Table 19 shows the volume of secure messages in the clinics that participated in this study. The clinics that have a longer history receive substantially more messages than clinics that only recently have
implemented this health IT application. Obviously clinicians who only receive one secure
message a week will experience less impact on their workflow than clinicians with a large volume of messages.
Another factor that has an impact on the workflow related to these health IT applications are the other tools and technology that are in use in a clinic. In all of the clinics studied, secure messaging is part of their patient portals, and consequently integrated into the electronic health record (EHR). The availability and compatibility of other health IT applications and tools thus has an impact on the secure messaging workflow. For example, if patients can use the e-prescribing application in their patient portal, they do not have to send a secure message to ask for a
medication refill. For e-forms the fact that the health IT applications are not able to transfer information directly to the EHR (in Clinic 1 and 4) has a major impact on the e-form workflow. Additional steps need to be taken (copying and pasting, printing and scanning) to transfer the information into the EHR and store it for later retrieval.
A third sociotechnical factor that has an impact on workflow is whether the clinic is part of a larger health care organization. This factor partly overlaps with the first factor that we mentioned. The independent clinics in our sample find it difficult to buy the same EHR that the larger health care organizations (HCOs) use. For example, Epic does not sell their product to small HCOs. Independent clinics have the choice to buy an EHR from a smaller vendor (as Clinic 2 did), or to contract with a larger HCO to use their EHR. For the latter option, clinics would know that (1) their EHR is compatible with the EHR of the larger HCO and (2) that they would be able to access medical records when patients are admitted to the hospital of the larger HCO. However, the clinics are also dependent for health IT support on the larger HCO, and the clinics are often not considered to be the highest priority when they need help or would like to make changes to the EHR.
A fourth sociotechnical factor that has an impact on the workflow related to patient-reported information isthe percentage of clinicians and staff who work part-time. Two clinics in our study (Clinics 4 and 6) employ a relatively large number of part-time clinicians (see Table 2).
Compared with full-time employees, part-time workers have less time to become familiar with and adapt to the health IT in that specific clinic. In general, part-time employees are less familiar with the health IT and the associated workflows. The scheduling of training in most clinics exacerbates this problem. Clinics often train their employees during lunch break on a specific day during the week. If the part-time employee does not work on that day, s/he would not receive the health IT training. Unfamiliarity with the health IT and lack of training in the use of health IT impact workflow.
A fifth sociotechnical factor that has an impact on the workflow related to patient-reported information is the organizational structure (organization) in the clinic. Clinic 2 has only one clinician who works with an MA and other nonclinical staff. This obviously affects workflow in the clinic. Only the provider can make clinical decisions, and so he triages secure messages. Secure messages add to the provider’s workload, although he is able to distribute some of the workload to the MA, the clinic manager, the receptionist, and the billing specialist. The other five clinics have implemented a patient-centered medical home (PCMH) model of care; doing that has an important impact on clinical workflow, but it takes time and effort before clinics become efficient at adhering to this model.65-67 Integrating patient-reported information in the PCMH also takes time, and therefore the history of PCMH implementation also influences the patient-
reported workflow. Clinic 1 has a longer history with PCMH than Clinics 5 and 6, and is more efficient in redistributing the tasks (see Figures 2, 5, and 6). In Clinic 1, clinicians and staff are involved in secure messaging, while in Clinics 5 and 6, tasks related to secure messaging are
Patient-provided information also has an impact on the tasks that clinicians, staff, and patients perform, and where the tasks are performed (interaction task and environment). Clinicians, staff, and patients all spend more time using computers, which may reduce the amount of face-to-face communication. This may add to clinicians’ workload. The tasks of triage nurses may become more difficult, because (1) the nurses lack the auditory cues received in phone and face-to-face conversation, and (2) secure messages may be long, complex, or include a lot of extraneous information. One advantage of secure messaging is that communication can be asynchronous: clinicians and staff are able to perform the tasks associated with a message when it is convenient for them. Patients have that same advantage, sending messages at times convenient for them.
Another sociotechnical factor that has an impact on the workflow related to patient-reported information is individual differences (the person). Within clinics, providers differ substantially in their attitudes toward secure messaging: some providers embrace secure messaging
enthusiastically and the opportunities it offers for improvement of patient-provider
communication. Other providers would prefer not to use it, especially because the time spent on secure messaging is not reimbursed. The preferences of the provider also affect how the provider and nurse collaborate. Some nurses read secure messages and even if they need provider input, first do research and route the message with a recommendation to the provider. Other nurses forward nearly all messages to the provider, and rarely do research first. These differences and individual preferences have an impact on the clinic workflow. Individual differences also play a role in the use of other health IT application. Clinic 1 implemented the headache e-form because the provider strongly preferred using this application to the paper forms that had previously been used. In Clinic 4, providers vary substantially in how they use the patient-reported outcomes (PRO) e-form data in the examination room. Finally, only a few clinicians chose to use the health IT application that allows patients to upload information into their patient portal. This application is available to 10 other providers who have chosen not to use it.
The last two sociotechnical factors that have an impact on the workflow related to patient- provided information are both related to patient characteristics. One factor that has an impact on secure messaging workflow is language (person). The patient population of Clinic 6 includes many patients who primarily speak Spanish, Hmong, or another language, but the clinic’s patient portal is available only in English, limiting the ability of these patients to use it. Several
publications have emphasized the importance of making a patient portal available in other
languages.68-70 We were not able to find any studies that examined the impact on workflow in the clinic of having a patient portal in multiple languages, but it would obviously create the need for bilingual staff who can address messages.