Content area
Background: The NIH Clinical Center in Bethesda, Maryland—the nation’s largest hospital dedicated to biomedical research—is planning to modernize its 20-year-old electronic health record (EHR) system, the Clinical Research Information System (CRIS EHR), which supports both patient care and research. However, staff report poor integration between CRIS EHR and clinical workflows, leading to inefficiencies, patient safety risks, and clinical quality challenges.
Methods: Guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the assessment systematically analyzed the EHR-workflow interface process to identify integration challenges and opportunities for improvement, emphasizing patient safety and clinical quality.
The study addressed three research questions:
- RQ1: What challenges exist in integrating the CRIS EHR with clinical workflows?
- RQ2: How can analyzing current workflows inform the development of future EHR functionalities?
- RQ3: What were participants' experiences with the clinical workflow modeling and redesign approach?
Data collection occurred in three phases:
- Phase 1: Analyzed CRIS EHR User Satisfaction survey data (2022–2023) to establish baseline knowledge of integration challenges.
- Phase 2: Conducted observations of six clinical workflow modeling and redesign sessions.
- Phase 3: Administered a self-reported survey to subject matter experts (SMEs) (n=85) to assess their perceptions and experiences using workflow modeling and redesign methods.
A cross-data comparison was used to analyze data across sources, identifying seven key themes: tailoring, standardization, interoperability, information availability, workflow intent, administrative burden, and training.
Results:
- RQ1: End-users identified clunky data entry processes, delays in accessing healthcare information, and complex system navigation as primary EHR-workflow integration challenges.
- RQ2: Observations of workflow modeling sessions revealed key issues, including data standardization problems, workflow disruptions due to lack of system integration, and inconsistent knowledge among users.
- RQ3: End-users found the workflow modeling and redesign method effective, as it captured the complexities of healthcare delivery and provided actionable insights.
- However, concerns arose regarding insufficient diversity in SME skillsets, which may have limited the accuracy of redesigned workflows.
- Triangulating data across multiple sources confirmed consistency across all seven thematic domains, strengthening the validity of the findings.
Conclusion: Based on these findings, the assessment developed the “e5” framework, which encompasses five key elements:
1. Emend
2. Enrich
3. Enhance
4. Employ
5. Empathy
This framework extends beyond EHR implementation, offering broader applicability to other digital healthcare technologies, including eHealth applications, the Internet of Things (IoT), and Artificial Intelligence. As healthcare organizations seek to enhance technological capabilities with their workflows, translating these findings into actionable strategies will be critical.
To ensure successful adoption and usability, the next EHR system must:
- Be customized for seamless workflow integration.
- Establish standardized guidelines for capturing, storing, and exchanging medical data.
- Implement consistent data formatting and communication standards across systems.
- Develop a comprehensive training program to equip end-users with essential skills.
By addressing these factors, the NIH Clinical Center can optimize EHR usability, allowing healthcare providers to focus more on patient care—reinforcing the core mission of healthcare.