Elsevier

Applied Ergonomics

Volume 78, July 2019, Pages 240-247
Applied Ergonomics

Technology barriers and strategies in coordinating care for chronically ill patients

https://doi.org/10.1016/j.apergo.2019.03.009Get rights and content

Highlights

  • Care managers frequently report technology barriers related to information (access and quality) and usability.

  • About half of the time, care managers report strategies to deal with barriers.

  • Information on barriers and strategies provides insights for work system redesign.

Abstract

Care managers who coordinate care for chronically ill patients in hospitals and outpatient settings use multiple health information technologies for accessing, processing, documenting, and communicating patient-related information. Using a combination of 41 interviews and observations of 15 care managers, we identified a range of technology-related barriers experienced by care managers (total of 163 occurrences). The barriers are related to (lack of) access to information, inadequate information, limited usefulness and usability of the technologies, challenges associated with using multiple health IT, and technical problems. In 43% of the occurrences, care managers describe strategies to deal with the technology barriers; these fit in three categories: nothing/delay (9 occurrences), work-arounds (32 occurrences), and direct action at the individual, team, and organization levels (29 occurrences). Our data show the adaptive capacity of care managers who develop various strategies to deal with technology barriers and are, therefore, able to care for chronically ill patients. This information can be used as input to work system redesigns.

Introduction

Improving the design of healthcare work systems is key to ensuring safety, productivity, and well-being of healthcare professionals and patients. This can be achieved by identifying barriers in their work systems (Alyousef et al., 2017; Carayon et al., 2011, 2014a; Hoonakker et al., 2013) and then developing interventions to remove the barriers. Although removing barriers represents a primary intervention for redesigning work systems and achieving positive outcomes, it may not always be possible (Carayon, 2009; Smith and Carayon-Sainfort, 1989). Therefore, we need to further explore the role of workers in adapting their work systems and adapting to their work systems, especially when they face barriers (Carayon et al., 2014b; Holden et al., 2013a). In this study, we examined strategies used by care managers in dealing with technology barriers.

Almost half of the U.S. population has one or more chronic conditions, such as heart failure (HF) or chronic obstructive pulmonary disease (COPD) (McDonald et al., 2007). Because patients with chronic conditions are cared for by multiple healthcare providers and hospitalized more often than the general population, they are likely to experience care coordination problems (McDonald et al., 2007). Well-coordinated care helps avoid delays in diagnosis and treatment, and confusion in what needs to be done for the patients (Bodenheimer, 2008); this work is often the responsibility of care managers (Carayon et al., 2015a; Maliski et al., 2004; Oliva, 2010; Steele et al., 2010). In order to coordinate care for patients with chronic conditions, care managers access, process, document, and communicate patient-related information. They use multiple technologies, such as EHR (Electronic Health Record), health information exchange (HIE), documentation systems, the telephone, and fax machines, to perform these coordinating activities. Research has identified various challenges or barriers experienced by care managers who use multiple health information technology (IT) systems when coordinating care for chronically ill patients. These barriers include usability problems (e.g., poor interface design, lack of interoperability between applications) and organizational barriers (e.g., no access to some health IT applications) (Alyousef et al., 2012, 2017; Carayon et al., 2012). Some technology barriers may be removed through system redesign (e.g. improving exchange of information between two technologies) while others may not be easily removed because of organizational, technical, or financial constraints. Therefore, it is important to understand how workers experience and deal with work system barriers, that is what type of strategies they develop and use in responding to and managing work system barriers (Durso et al., 2015a; Holden et al., 2013b).

Strategies have been defined and labeled in multiple ways. Different bodies of literature describe strategies or actions taken by individuals when faced with safety hazards, job stressors, and other problems:

  • (1)

    resilience engineering (Hollnagel et al., 2006),

  • (2)

    stress coping theory (Lazarus and Folkman, 1984),

  • (3)

    user adaptation to/of technology (Beaudry and Pinsonneault, 2005; Tyre and Orlikowski, 1994),

  • (4)

    problem solving (Tucker et al., 2002), and

  • (5)

    work-arounds (Blijleven et al., 2017; Halbesleben et al., 2008; Koppel et al., 2008; Patterson, 2018).

The resilience engineering literature has defined three strategies that can be used to deal with safety hazards (Hollnagel et al., 2006): anticipation (i.e., knowing what to expect), attention (i.e. knowing what to look for), and response (i.e., knowing what to do). An example of anticipatory strategy is when a nurse sorts medication orders by name in the bar coding medication administration technology before printing the medication order list (Holden et al., 2013b). These strategies represent resilience behaviors of individuals or organizations when faced with disturbances and safety hazards. Lazarus and Folkman (1984) defined coping as the cognitive and behavioral efforts used to deal with job stressors or demands. Coping strategies either target the emotional response to the stressor or demand, or focus on problem solving, which involves dealing directly with the stressor or demand. The literature on technology user adaptation describes strategies that users develop to deal with “significant information technology events that occur in their work environment” (Beaudry and Pinsonneault, 2005, p. 496). Similar to the stress coping theory (Lazarus and Folkman, 1984), this literature defines strategies that are either emotion-focused or problem-focused. Problem solving strategies have been further identified and characterized by Tucker and colleagues (Tucker, 2004; Tucker et al., 2002; Tucker and Spear, 2006). They described strategies used by nurses when dealing with operational problems, such as doing whatever is necessary to continue patient care. They found that nurses primarily used first-order problem-solving strategies that tackle problems at the individual level of action. An example of first-order problem solving strategy occurred when a nurse has to print security tags for two babies in a row, but does not look for why the security tags were missing (Tucker et al., 2002). Second-order problem solving rarely occurred and involved communicating to the person or department responsible for the problem or bringing it to the managers’ attention; these strategies tackled team and organization levels of action.

Work-arounds, another type of strategy, represent “behaviors of users to overcome perceived limitations (workflow problems) in a technical system” (Friedman et al., 2014). Work-arounds have been found in the hospital environment where “informal temporary practices” are used to manage exceptions to normal workflow (Halbesleben et al., 2010; Halbesleben et al., 2008). Work-arounds often occur when healthcare providers deal with problems created by technologies (Carayon et al., 2007; Ferneley and Sobreperez, 2006; Koppel et al., 2008; Mount-Campbell et al., 2019; Patterson, 2018). For example, nurses felt it was easier to document medication administration using bar code medication administration technology before the medication was given (Carayon et al., 2007). This work-around can represent a safety hazard as the patient may not take the medication, despite the medication having been documented as administered.

In our research, we defined a strategy as a behavioral or cognitive activity aimed at dealing with a work system barrier. Based on the literature (Durso et al., 2015a,b; Holden et al., 2013b), we identified three types of strategies in dealing with a work system barrier: (1) doing nothing or waiting and delaying performance (similar to the ‘ignore’ strategy of Durso et al.), (2) working around the barrier either in reaction to or in anticipation of a barrier (similar to the ‘work-around’ strategy of Durso et al.), and (3) tackling the barrier directly and fixing or attempting to fix it [problem-focused] (similar to the ‘mitigate’ and ‘prevent’ strategies of Durso et al.) (see Fig. 1). We also recognized that problem-focused strategies (direct action) address various levels of action: the individual, team, or organization levels (Li et al., 2014; Tucker and Edmondson, 2003).

In this research, we applied the conceptual model of strategies displayed in Fig. 1 to the domain of care coordination for chronically ill patients. The conceptual model integrates two components of the Systems Engineering Initiative for Patient Safety (SEIPS) model (Carayon et al., 2006, 2014a,b): the work system elements, and the feedback loops; strategies are conceptualized as activities in reaction to strategies created by the work system and are, therefore, examples of the feedback loops in the SEIPS model. We focused on the technology element of the work system (Carayon, 2009; Smith and Carayon-Sainfort, 1989) and technology-related barriers, and described the range of technology barriers experienced by care managers. We then examined care managers’ strategies in dealing with such barriers.

Several studies have described strategies used by healthcare workers in dealing with technology problems or barriers (Durso et al., 2015a; Holden et al., 2013b; Mount-Campbell et al., 2019; Novak et al., 2013; Tucker and Edmondson, 2003). These studies focus on healthcare workers in the hospitals, such as critical care nurses (Durso et al., 2015a,b). We added to this body of knowledge by studying care managers in both inpatient and outpatient settings. In a manner similar to Durso et al. (2015a), we also expanded existing research on strategies by examining the specific relationship between barriers and strategies; this is a major innovation of this study. Our study addressed the following research questions:

  • Do all barriers elicit strategies?

  • Do certain types of barrier relate to certain types of strategy?

Section snippets

Setting and sample

Data for this study were collected in the context of a large-scale project funded by the US Department of Health and Human Services. The so-called Keystone Beacon project aimed to expand an existing payor-based outpatient care management model (Maeng et al., 2012; Steele et al., 2010) and created an integrated system of care managers that were deployed across five counties in central Pennsylvania for about two years. Inpatient care managers (CMs) were located in hospitals, outpatient CMs were

Technology barriers

Through an iterative inductive process, we identified a total of 163 occurrences of technology-related barriers, organized in six categories of barriers (see Table 2). Occurrences of inadequate access to health IT and other tools frequently happened during the initiation of the Keystone Beacon project. For instance, some of the care managers had to wait to get access to the local EHR at their hospital or primary care clinic. Inadequate information in health IT was the technology barrier most

Discussion

Using data from 41 interviews and observations of 15 care managers performed over a 21-month period, we identified a large number of technology-related barriers (total of 163 occurrences) that ranged from usability and usefulness, to inadequate access to technology or inadequate information in the technology, to technical problems. Our results are in line with other studies that have found frequent technology-related barriers experienced by healthcare professionals. For instance, Durso et al.

Conclusion

Care managers who coordinate care for chronically ill patients face a range of technology barriers and, for about half of the barrier occurrences, describe strategies for dealing with those barriers. Future research should continue to explore strategies developed by workers in dealing with work system barriers, in particular the role of strategies in workload creation and/or management. Because work-arounds were the most frequently reported strategy, we also need to continue examining the

Acknowledgements

Funding for this research was provided by the US Office of the National Coordinator for Health IT Beacon Community Program [award No. 90BCE001301] and was supported by the Clinical and Translational Science Award (CTSA) program, previously through the National Center for Research Resources (NCRR) grant 1UL1RR025011, now by the Center for Advancing Translational Sciences (NCATS), grant 9U54TR000021. The content is solely the responsibility of the authors and does not necessarily represent the

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