Clinician and staff experiences with frustrated patients during an electronic health record transition: a qualitative case study

BACKGROUND

Electronic health record (EHR) transitions are known to be highly disruptive, can drastically impact clinician and staff experiences, and may influence patients' experiences using the electronic patient portal. Clinicians and staff can gain insights into patient experiences and be influenced by what they see and hear from patients. Through the lens of an emergency preparedness framework, we examined clinician and staff reactions to and perceptions of their patients' experiences with the portal during an EHR transition at the Department of Veterans Affairs (VA).

METHODS

This qualitative case study was situated within a larger multi-methods evaluation of the EHR transition. We conducted a total of 122 interviews with 30 clinicians and staff across disciplines at the initial VA EHR transition site before, immediately after, and up to 12 months after go-live (September 2020-November 2021). Interview transcripts were coded using a priori and emergent codes. The coded text segments relevant to patient experience and clinician interactions with patients were extracted and analyzed to identify themes. For each theme, recommendations were defined based on each stage of an emergency preparedness framework (mitigate, prepare, respond, recover).

RESULTS

In post-go-live interviews participants expressed concerns about the reliability of communicating with their patients via secure messaging within the new EHR portal. Participants felt ill-equipped to field patients' questions and frustrations navigating the new portal. Participants learned that patients experienced difficulties learning to use and accessing the portal; when unsuccessful, some had difficulties obtaining medication refills via the portal and used the call center as an alternative. However, long telephone wait times provoked patients to walk into the clinic for care, often frustrated and without an appointment. Patients needing increased in-person attention heightened participants' daily workload and their concern for patients' well-being. Recommendations for each theme fit within a stage of the emergency preparedness framework.

CONCLUSIONS

Application of an emergency preparedness framework to EHR transitions could help address the concerns raised by the participants, (1) mitigating disruptions by identifying at-risk patients before the transition, (2) preparing end-users by disseminating patient-centered informational resources, (3) responding by building capacity for disrupted services, and (4) recovering by monitoring integrity of the new portal function.

Which patient and surgeon characteristics are associated with surgeon experience of stress during an office visit?

Objective

To determine clinician and patient factors associated with the surgeon feelings of stress, futility, inadequacy, and frustration during an office visit.

Methods

A survey-based experiment presented clinical vignettes with randomized patient factors (such as symptom intensity, the number of prior consultations, and involvement in a legal dispute) and feeling behind schedule in order to determine which are most related to surgeon ratings of stress, futility, inadequacy, and frustration on 11-point Likert scales.

Results

Higher surgeon stress levels were independently associated with women patients, multiple prior consultations, a legal dispute, disproportionate symptom intensity, and being an hour behind in the office. The findings were similar for feelings of futility, inadequacy, and frustration.

Conclusion

Patient factors potentially indicative of mental and social health opportunities are associated with greater surgeon-rated stress and frustration.

Innovation

Trainings for surgeon self-awareness and effective communication can transform stressful or adversarial interactions into an effective part of helping patients get and stay healthy by diagnosing and addressing psychosocial aspects of the illness.

Level of evidence

N/a.

'When the picture does not really tell the story'- A qualitative exploration of the MRI report of findings as a means for generating shared diagnostic meaning during the management of patients suffering from persistent spinal pain

OBJECTIVES

To explore the magnetic resonance imaging (MRI) feedback report as a health care encounter for generating shared diagnostic meaning.

METHODS

An exploratory, qualitative case study was conducted using video observation of the MRI report of findings, individual face-to-face and telephonic interviews.

RESULTS

From fourteen distinct encounters, three key themes emerged, these being: 'a powerful shared experience, 'a legacy of biomedical thinking' and 'clinical practice quandaries'. Generally speaking, the MRI encounter was observed to be both an effective and satisfying method for developing shared diagnostic meaning. However, in instances where a structure-based diagnosis could not be reasonably established, clinicians experienced doubts in what to present in a 'soft report'. A feature of these was the communication of speculative causal feedback, based on non-visualised structures and/or incidental findings observed.

CONCLUSION

Shared diagnostic meaning can result from a 'soft' MRI report of findings. However, the emergence of diagnostic closure is not guaranteed. Further exploration of this phenomenon in the context of shared decision making and the therapeutic alliance is warranted.

PRACTICE IMPLICATIONS

Pre-feedback peer conferences might be considered in order to standardise the information communicated to patients. Clinicians might also consider limiting the MRI scan as a visual aid in 'soft' reports.

Clinicians' experience of providing care: a rapid review

BACKGROUND

Health care services internationally are refocussing care delivery towards patient centred, integrated care that utilises effective, efficient and innovative models of care to optimise patient outcomes and system sustainability. Whilst significant efforts have been made to examine and enhance patient experience, to date little has progressed in relation to provider experience. This review aims to explore this knowledge gap by capturing evidence of clinician experience, and how this experience is defined and measured in the context of health system change and innovation.

METHODS

A rapid review of published and grey literature review was conducted utilising a rapid evidence assessment methodology. Seventy-nine studies retrieved from the literature were included in the review. Fourteen articles were identified from the grey literature search and one article obtained via hand searching. In total, 94 articles were included in the review. This study was commissioned by and co-designed with the New South Wales, Ministry of Health.

RESULTS

Clinician experience of delivering health care is inconsistently defined in the literature, with identified articles lacking clarity regarding distinctions between experience, engagement and work-related outcomes such as job satisfaction. Clinician experience was commonly explored using qualitative research that focused on experiences of discrete health care activities or events in which a change was occurring. Such research enabled exploration of complex experiences. In these contexts, clinician experience was captured in terms of self-reported information that clinicians provided about the health care activity or event, their perceptions of its value, the lived impacts they experienced, and the specific behaviours they displayed in relation to the activity or event. Moreover, clinician's experience has been identified to have a paucity of measurement tools.

CONCLUSION

Literature to date has not examined clinician experience in a holistic sense. In order to achieve the goals identified in relation to value-based care, further work is needed to conceptualise clinician experience and understand the nature of measurement tools required to assess this. In health system application, a broader 'clinician pulse' style assessment may be valuable to understand the experience of clinical work on a continuum rather than in the context of episodes of change/care.

Exploring interdisciplinary teamwork to support effective ward rounds

PURPOSE

This paper aims to explore if health professionals share understanding of teamwork that supports collaborative ward rounds.

DESIGN/METHODOLOGY/APPROACH

A purpose-designed survey was conducted in two acute medical and two rehabilitation wards from a metropolitan teaching hospital. Medical officers, nurses and allied health professionals participated. To understand characteristics that support collaborative ward rounds, questions developed from literature and industry experience asked: what are the enablers and challenges to teamwork; and what are clinicians' experiences of positive teamwork? Descriptive and thematic analyses were applied to the dimensions of effective teamwork as a framework for deductive coding.

FINDINGS

Seventy-seven clinicians participated (93% response rate). Findings aligned with dimensions of teamwork framework. There was no meaningful difference between clinicians or specialty. Enablers to teamwork were: effective communication, shared understanding of patient goals, and colleague's roles. Challenges were ineffective communication, individual personalities, lack of understanding about roles and responsibilities, and organisational structure. Additional challenges included: time; uncoordinated treatment planning; and leadership. Positive teamwork was influenced by leadership and team dynamics.

PRACTICAL IMPLICATIONS

Ward rounds benefit from a foundation of collaborative teamwork. Different dimensions of teamwork present during ward rounds support clinicians' shared understanding of roles, expectations and communication.

ORIGINALITY/VALUE

Rounds such as structured rounding, aim to improve teamwork. Inverting this concept to first develop effective collaboration will support team adaptability and resilience. This enables teams to transition between the multiple rounding processes undertaken in a single ward. The emphasis becomes high-quality teamwork rather than a single rounding process.

Staff perspectives of a model of access and triage for reducing waiting time in ambulatory services: a qualitative study

Background

Specific Timely Appointments for Triage (STAT) is an intervention designed to reduce waiting time in community outpatient health services, shown to be effective in a large stepped wedge cluster randomised controlled trial. STAT combines initial strategies to reduce existing wait lists with creation of a specific number of protected appointments for new patients based on demand. It offers an alternative to the more traditional methods of demand management for these services using waiting lists with triage systems. This study aimed to explore perceptions of clinicians and administrative staff involved in implementing the model.

Method

Semi-structured interviews with 20 staff members who experienced the change to STAT were conducted by an independent interviewer. All eight sites involved in the original trial and all professional disciplines were represented in the sample. Data were coded and analysed thematically.

Results

Participants agreed that shorter waiting time for patients was the main advantage of the STAT model, and that ongoing management of caseloads was challenging. However, there was variation in the overall weight placed on these factors, and therefore the participants’ preference for the new or previous model of care. Perceptions of whether the advantages outweighed the disadvantages were influenced by five sub-themes: staff perception of how much waiting matters to the patient, prior exposure to the management of waiting list, caseload complexity, approach and attitude to the implementation of STAT and organisational factors.

Conclusions

The STAT model has clear benefits but also presents challenges for staff members. The findings of this study suggest that careful preparation and management of change and active planning for known fluctuations in supply and demand are likely to help to mitigate sources of stress and improve the likelihood of successful implementation of the STAT model for improving waiting times for patients referred to community outpatient services.