Background The majority of U.S hospitals have implemented electronic health records (EHRs). While the benefits of EHRs have been widely touted, little is known about their effects on inpatient care, including how well they meet workflow needs and support care. Objective Assess the extent to which EHRs support care team workflow during hospital morning rounds. Design We applied a mixed-method approach including observations of care teams during morning rounds, semi-structured interviews and an electronic survey of hospital inpatient clinicians. Structured field notes taken during observations were used to identify workflow patterns for analysis. We applied a grounded theory approach to extract emerging themes from interview transcripts and used SPSS Statistics 24 to analyze survey responses. Setting Medical units at a major teaching hospital in New England. Results Data triangulation across the three analyses yielded four main findings: (1) a high degree of variance in the ways care teams use EHRs during morning rounds. (2) Pervasive use of workarounds at critical points of care (3) EHRs are not used for information sharing and frequently impede intra-care team communication. (4) System design and hospital room settings do not adequately support care team workflow. Conclusions Gaps between EHR design and the functionality needed in the complex inpatient environment result in lack of standardized workflows, extensive use of workarounds and team communication issues. These issues pose a threat to patient safety and quality of care. Possible solutions need to include improvements in EHR design, care team training and changes to the hospital room setting.

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ObjectiveThe traditional dyadic dynamics of the medical encounter has been altered into a triadic relationship by introducing the computer into the examination room. This study defines Patient-Doctor-Computer Communication (PDCC) as a new construct and provides an initial validation process of an instrument for assessing PDCC in the computerized exam room: the e-SEGUE.Material and methodsBased on the existing literature, a new construct, PDCC, is defined as the physician’s ability to provide patient-centered care while using the computer during the medical encounter. This study elucidates 27 PDCC-related behaviors from the relevant literature and state of the art models of PDCC. These were embedded in the SEGUE communication assessment framework to form the e-SEGUE, a communication skills assessment tool that integrates computer-related communication skills. Based on Mackenzie et al.’s methodological approach of measurement construction, we conducted a two-phased content validity analysis by a general and expert panels of the PDCC behaviors represented in the e-SEGUE. This study was carried out in an environment where EMR use is universal and fully integrated in the physicians’ workflow.ResultsThe panels consisted of medical students, residents, primary care physicians, healthcare leaders and faculty of medicine members, who rated and provided input regarding the 27 behaviors. Overall, results show high level of agreement with 23 PDCC-related behaviors.ConclusionThe PDCC instrument developed in this study, the e-SEGUE, fared well in a rigorous, albeit initial, validation process has a unique potential for training and enhancing patient-doctor communication (PDC) in the computerized examination room pending further development.