Workarounds in Electronic Health Record Systems and the Revised Sociotechnical Electronic Health Record Workaround Analysis Framework: Scoping Review

Abstract

Background Electronic health record (EHR) system users devise workarounds to cope with mismatches between workflows designed in the EHR and preferred workflows in practice. Although workarounds appear beneficial at first sight, they frequently jeopardize patient safety, the quality of care, and the efficiency of care. Objective This review aims to aid in identifying, analyzing, and resolving EHR workarounds; the Sociotechnical EHR Workaround Analysis (SEWA) framework was published in 2019. Although the framework was based on a large case study, the framework still required theoretical validation, refinement, and enrichment. Methods A scoping literature review was performed on studies related to EHR workarounds published between 2010 and 2021 in the MEDLINE, Embase, CINAHL, Cochrane, or IEEE databases. A total of 737 studies were retrieved, of which 62 (8.4%) were included in the final analysis. Using an analytic framework, the included studies were investigated to uncover the rationales that EHR users have for workarounds, attributes characterizing workarounds, possible scopes, and types of perceived impacts of workarounds. Results The SEWA framework was theoretically validated and extended based on the scoping review. Extensive support for the pre-existing rationales, attributes, possible scopes, and types of impact was found in the included studies. Moreover, 7 new rationales, 4 new attributes, and 3 new types of impact were incorporated. Similarly, the descriptions of multiple pre-existing rationales for workarounds were refined to describe each rationale more accurately. Conclusions SEWA is now grounded in the existing body of peer-reviewed empirical evidence on EHR workarounds and, as such, provides a theoretically validated and more complete synthesis of EHR workaround rationales, attributes, possible scopes, and types of impact. The revised SEWA framework can aid researchers and practitioners in a wider range of health care settings to identify, analyze, and resolve workarounds. This will improve user-centered EHR design and redesign, ultimately leading to improved patient safety, quality of care, and efficiency of care.

When workarounds aggravate misfits in the use of electronic health record systems

“…Our study is built upon and integrates existing literatures on misfits and on workarounds in healthcare settings. These previous healthcare‐related studies have informed and inspired our research, including Blijleven et al (2022), Boonstra et al (2021), King et al (2014), Petrakaki and Kornelakis (2016), Strong and Volkoff (2010), and Zhou et al (2011).…”

“…Workarounds have frequently been studied in the IS field (e.g. Alter, 2014;Azad & King, 2012;Beerepoot et al, 2019;Blijleven et al, 2022;Ferneley & Sobreperez, 2006;Ignatiadis & Nandhakumar, 2009). Ejnefjäll and Ågerfalk's (2019) review of this literature shows that workarounds can have various sources.…”

“…Further, workarounds can even be part of learning how to cope with the requirements and limitations of a new system and may play a role in institutionalising the system (Malaurent & Karanasios, 2020). Indeed, workarounds have been claimed to contribute to the success of EHR implementation (Blijleven et al, 2022).…”

“…Our findings support Ejnefjäll and Ågerfalk's (2019) ideas concerning the relationship between misfits and workarounds and add to them by showing how user-aggravated misfits may emerge in response to experienced misfits caused by impositions or deficiencies. We also build on the work of Blijleven et al (2022) assigning roles and authorities, imposing rules, criteria and procedures, and adopting a standardised data model (e.g. Ejnefjäll & Ågerfalk, 2019).…”

“…Within this literature, much attention has been devoted to responses that constitute workarounds (e.g. Alter, 2014; Azad & King, 2012; Bartelheimer et al, 2023; Beerepoot et al, 2019; Blijleven et al, 2022; Ejnefjäll & Ågerfalk, 2019; Ferneley & Sobreperez, 2006; Ignatiadis & Nandhakumar, 2009). A central debate revolves around the legitimacy of workarounds, as these can have both positive and negative consequences (Ejnefjäll & Ågerfalk, 2019).…”