How nurses and doctors communicate—or don't communicate—using health information technology is the focus of a multi-year study funded by the federal Agency for Healthcare Research and Quality.
The life-and-death importance of nurse-physician communication and the use of electronic health records came to a frightening, critical head last week when a nurse noted in a sick patient's EHR that the patient had recently traveled to the United States from Africa.
Milisa Manojlovich, PhD, RN, CCRN
Despite the note, the patient was sent home. He later returned to the hospital and was eventually diagnosed with the Ebola virus.
Revising an earlier statement that blamed the bungled incident on a "flaw" in its (Epic) EHR system, Texas Health Resources backtracked last Friday saying, "As a standard part of the nursing process, the patient's travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician's workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event."
In either event if the nurse used the EHR alone to communicate that critical piece of patient information, it obviously didn't work. According to Milisa Manojlovich, PhD, RN, CCRN, associate professor at the University of Michigan School of Nursing, it's a case of the medium not matching the message.
Leaving too Much to Chance
"The Ebola example is a great example of communication technology not being used appropriately," she says. "There needed to be a sense that the medium of the electronic health record is not the best for this."
An EHR note alone leaves too much to chance. In cases like this, the communication medium should be more direct, such as a phone call, a page, or face-to-face.
"On the other hand, why is it that nursing notes are not routinely read?" Manojlovich asks. Physicians were obviously to blame here, too, since they it seems they either didn't read the nurse's note or disregarded its importance.
How nurses and doctors communicate—or don't communicate—using health IT is what Manojlovich will spend the next four years studying. She is the primary investigator using a $1.6 million grant from the federal Agency for Healthcare Research and Quality to explore how communication technologies such EHRs, email, and pagers are being used and where common failures occur, focusing on nurse-physician communication.
The study began this month, and in light of the Ebola miscommunication, not a moment too soon. According to Manojlovich, electronic communication's increasing prevalence has resulted in decreased face-to-face communication between practitioners, resulting in situations like the one in Texas, where important information wasn't conveyed, perhaps because it was inappropriately communicated.
A Critical Miscue
In the announcement of the study, Manojlovich pointed to another such instance of the medium not matching the message, describing previous research in which physicians were observed putting STAT orders in the computer, but not notifying the nurses in any other way. The nurses, it turned out, were only required to check the computer for orders every two hours.
As health IT gets rolled out around the world with unprecedented speed, it's critical that the healthcare industry figures out when it's helpful and when it's unhelpful or even dangerous.
Manojlovich points to a perspective piece in the Journal of the American Medical Informatics Association titled "The Dangerous Decade," in which the authors posit that health IT is "at roughly the same place the aviation industry was in the 1950s with respect to system safety" and that related harms are sure to increase as health IT becomes more prevalent.
This combination of venturing into uncharted territory and a great potential for harm makes the patient safety stakes very, very high.
"We know there's going to be more health IT than ever before," Manojlovich says. "We really need to understand how it is being used in healthcare."
Manojlovich's study will include three components. First, the researchers will survey hospitals to get information about whether they have an EHR; whether nurses and doctors have computers; whether the hospitals use devices such as pagers, email, and electronic whiteboards; and other basic usage information.
"We want to just get a lay of the land," Manojlovich says. "We need this information because it's crucial to establishing how key clinical information is exchanged."
Next, the researchers will divide the respondents into two subsamples, depending on their level of technology usage. Via phone interviews, researchers will ask about how the technology influences their work, its impact on how nurses and doctors talk to each other and their relationships, and whether and how technology has changed their workflow.
The last stage will involve the researchers visiting four hospitals and observing the doctors and nurses as they work and use technology, as well as conducting focus groups. Researchers will also ask the hospitals for technology usage updates through the duration of the four-year study.
In the end, Manojlovich and her team aim to use their findings to make some recommendations about the use of health IT in nurse-patient communication, and also perhaps design technology to support the multiple decision-making that goes on in a hospital.
Manojlovich says that technology is becoming pervasive everywhere, more quickly than society can understand its effects.
"It's changing the way we live our lives in general, so it's not unusual then to think that it also has an influence in healthcare," she says. "But it might be more critical in healthcare because you're dealing with patient lives."
Alexandra Wilson Pecci is an editor for HealthLeaders.