Understanding the Digital Disruption of Health Care: An Ethnographic Study of Real-Time Multidisciplinary Clinical Behavior in a New Digital Hospital

Abstract

Background Understanding electronic medical record (EMR) implementation in digital hospitals has focused on retrospective “work as imagined” experiences of multidisciplinary clinicians, rather than “work as done” behaviors. Our research question was “what is the behavior of multidisciplinary clinicians during the transition to a new digital hospital?” Objectives The aim of the study is to: (1) Observe clinical behavior of multidisciplinary clinicians in a new digital hospital using ethnography. (2) Develop a thematic framework of clinical behavior in a new digital hospital. Methods The setting was the go-live of a greenfield 182-bed digital specialist public hospital in Queensland, Australia. Participants were multidisciplinary clinicians (allied health, nursing, medical, and pharmacy). Clinical ethnographic observations were conducted between March and April 2021 (approximately 1 month post-EMR implementation). Observers shadowed clinicians in real-time performing a diverse range of routine clinical activities and recorded any clinical behavior related to interaction with the digital hospital. Data were analyzed in two phases: (1) content analysis using machine learning (Leximancer v4.5); (2) researcher-led interpretation of the text analytics to generate contextual meaning and finalize themes. Results A total of 55 multidisciplinary clinicians (41.8% allied health, 23.6% nursing, 20% medical, 14.6% pharmacy) were observed across 58 hours and 99 individual patient encounters. Five themes were derived: (1) Workflows for clinical documentation; (2) Navigating a digital hospital; (3) Digital efficiencies; (4) Digital challenges; (5) Patient experience. There was no observed harm attributable to the digital transition. Clinicians primarily used blended digital and paper workflows to achieve clinical goals. The EMR was generally used seamlessly. New digital workflows affected clinical productivity and caused frustration. Digitization enabled multitasking, clinical opportunism, and benefits to patient safety; however, clinicians were hesitant to trust digital information. Conclusion This study improves our real-time understanding of the digital disruption of health care and can guide clinicians, managers, and health services toward digital transformation strategies based upon “work as done.”

The Impact of Digital Hospitals on Patient and Clinician Experience: Systematic Review and Qualitative Evidence Synthesis

“…These inconsistencies are likely reflective of the various contextual factors that influence experience, such as intervention design or stage of implementation. It is likely that the quantitative finding of mixed usability of EMRs explains clinician reliance on hybrid (digital and paper) workflows revealed in the qualitative evidence synthesis as clinicians seek to maintain their clinical workflow standard and validate data using additional sources of truth, such as paper [10]. The effect of digital hospitals on clinician-reported patient safety and clinician ability to deliver care were mixed; there was acknowledgment that digitization primarily reduces medication error risk but creates new risks driven by questionable data quality.…”

“…A digital hospital uses a comprehensive electronic medical record (EMR) to achieve its clinical goals [7] and is becoming the predominant method of care delivery worldwide. These new digital hospital environments radically disrupt well-rehearsed clinical workflows and create unfamiliar environments for patients and clinicians, potentially affecting quality, safety, and experience of care [8][9][10].…”

“…It has been difficult to determine the value of digital hospital implementations as what is considered valuable changes over time and place and from person to person [11]. Previous studies evaluating digital health implementations have focused on three domains: (1) improving patient or hospital outcomes using quantitative evaluation [12]; (2) exploring patient [13] and clinician behavior, workflows, and attitudes toward EMRs or digital hospital transformations [10]; and (3) quantifying value using economic evaluations [4]. Evidence to date demonstrates conflicting impacts of EMRs on hospital practice, with positive indications for medication safety, guideline adherence, and decision support [12,14] and negative indications for physician-patient communication, staff attitude, and workflow disruption [15,16].…”

“…The experience of patients and clinicians has yet to be explored as important contributors to the Quadruple Aim. Previous evaluations of clinician experience have focused on individual retrospective recalls of attitudes, perceptions of EMR implementation [ 10 ], and observational time and motion studies [ 22 ]. Existing patient experience research has focused on bespoke digital systems for patient use (eg, internet-based care technologies, web-based patient platforms, and mobile health apps) or emerging trends (eg, COVID-19 impacts, effects of specific technologies, research methods, and new technologies) [ 23 , 24 ].…”

Identifying the factors influencing enterprise digital transformation intention: an empirical study based on net effects and joint effects

“…In terms of industry scope, digital transformation has penetrated various industries, such as manufacturing (Scott and Orlikowski, 2022), tourism (Busulwa et al ., 2022), agriculture (Rijswijk et al ., 2021), education (Timotheou et al ., 2022), healthcare (Canfell et al ., 2022), and transportation (Tijan et al ., 2021).…”