Measuring the impact of technology on nurse workflow: a mixed methods approach.

Abstract

Background: Investment in health information technology (HIT) is rapidly accelerating. The absence of contextual or situational analysis of the environment in which HIT is incorporated makes it difficult to measure success or failure. The methodology introduced in this paper combines observational research with time-motion study to measure the impact of new HIT on clinician workflow. Objectives: The purpose of this research is the investigation of nurse workflow before and after the implementation of video care delivery in a telephone care delivery setting. The aims are achieved using a sequential mixed methods protocol that explores the workflow of telephone and video care delivery and uses this information to describe the consequences and measure the efficiency of the two delivery modes. Methods: The first phase is a qualitative exploration of nurse workflow in which ethnographic data is collected from nurse informants at a large, urban general pediatrics clinic. The qualitative data is analyzed within the framework of distributed cognition to identify the activity and interaction themes of telephone and video care delivery. The qualitative themes are connected to the quantitative protocol by developing a data collection instrument for the second phase of the protocol: a time-motion study comparing the time (efficiency) of telephone and video care delivery. Qualitative and quantitative results are merged to identify the consequences of adding video care delivery to nurse workflow. The mixed methods protocol is applied to two settings within the general pediatrics clinic: triage office and care coordination office. Results: The workflow of both triage and care coordination are distributed across time, space, persons and artifacts. In both settings, the primary workflow task is coordinating an episode of care and the primary interactions occur with providers, parents and the electronic medical record. The impact of video care delivery on nurse workflow differs between the two settings. In the triage office, adding video care delivery to the existing workflow is disruptive, requiring significantly more time than telephone care delivery. Despite the disruptive effect, triage nurses rate video care delivery as more useful than telephone. In the care coordination office, video care delivery is a standard component of the workflow. It is not disruptive to nurse workflow and does not require significantly more time than telephone care delivery. Applying the mixed method protocol in similar settings provides initial validation for evaluating the impact of new HIT on nurse workflow. Conclusion: Analyzing the quantitative time-motion data within an interpretive framework provides insight into the consequences of new HIT. Adding video to an existing triage workflow results in positive and negative consequences that increase the time spent on workflow tasks. Video facilitates new interaction and communication patterns with parents and children that allow triage nurses to visually supplement and verify their ‘telephone’ assessment, a positive consequence. The internal network architecture creates unpredictable video transmission errors that cause frequent waiting and video care delivery troubleshooting, a negative consequence. Including video as a standard component of the care coordination workflow has a neutral effect on the time of workflow tasks. Video care delivery supports the proactive interactions and increased nurse scope of practice of care coordination provided by an advanced practice nurse. Use of the mixed methods protocol to evaluate other HIT is a necessary step to ensure the methodologies transferability and applicability for use in meta-analysis.