!

Leveraging Documentation in the Electronic Health Record to Support Interprofessional

Communication: A Delphi Study

A Dissertation Presented to the Faculty of the College of Nursing

Villanova University

In Partial Fulfillment of the Requirements for the Degree

Doctor of Philosophy in Nursing

by

Jennifer A. Thate, MSN, RN, CNE

Villanova University, College of Nursing

August 30, 2017

Dissertation Committee

Chair: Helene Moriarty, PhD, RN, FAAN

Committee member: Ruth McDermott-Levy, PhD, MPH, RN

Committee member: Sarah A. Collins, PhD, RN





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Acknowledgements

This dissertation would not have been possible without the help and support of faculty,

colleagues, friends, and family. It is with a grateful heart that I acknowledge those people who

have provided assistance, offered guidance, and encouraged me throughout this process. To

begin, I would like to thank the members of the expert panel who graciously gave their time and

shared their expertise. Without them, this research would not have been possible.

I would like to express my sincere gratitude to my dissertation committee. To my chair,

Dr. Helene Moriarty—your persistent attention to the details demonstrated your investment in

me and this project. I am certain that my final product is stronger due to your input. Dr.

Moriarty—you set the bar high, but also provided guidance and encouragement to ensure my

success. To Dr. Ruth McDermott-Levy—I was struck by your warmth when we first met, and

your steady, calm demeanor has been a source of sanity for me throughout this process. I am so

grateful to have had you on my team. Your experience with the Delphi method has been a great

asset as well. And to Dr. Sarah Collins, whose work inspired me to embark on this study—I am

so grateful that you responded to my e-mail and took a risk on mentoring me. You have opened

so many doors for me, facilitated access to Partners HealthCare System and Brigham and

Women’s Hospital to conduct my research, and provided me with invaluable insight and

feedback through regular phone calls over the past few years. Thank you for investing in me!

I wish to also thank the faculty at Villanova University for their guidance throughout the

program and for embracing me and my fellow students as colleagues. I would especially like to

thank the director of the PhD program, Dr. Nancy Sharts-Hopko—Thank you for your belief in

me from day one when I was struggling to believe in myself. Your willingness to serve as a

!!!

sounding board and to provide wise counsel has kept me grounded. I hope to emulate your

example as an educator.

To my readers, Dr. Lesley Perry and Dr. Melissa O’Connor—It is a daunting task to

engage with a dissertation. Thank you for your careful review and thoughtful feedback.

To the cohort of students that started the Nursing Ph.D. program with me—I am grateful

for your humor and encouragement throughout this process. I am especially grateful to Serah,

Khamis, Susan, and Trish for continuing to cheer me on towards the finish line. Trish, your

unwavering support and thoughtful texts and calls—to listen and seek to understand—have

helped me to keep putting one foot in front of the other.

Lastly, I would like to thank my family for their unconditional love and support. To my

sister and her family, “Aunt” Cheryl, and my parents—thank you for loving and caring for my

two boys when I did not have enough hours in the day to adequately do so myself. To Dad—

thanks for reading and providing feedback, and instilling in me the belief that I can do anything I

set my mind to. To Mom—for sewing costumes or seriously, whatever was required, to keep us

afloat. To Berkeley and Ethan—thanks for being so understanding as we have walked through

this journey together as a family. Thank you, boys, for helping me to celebrate each victory

along the way, big or small. It has been a joy to watch you grow and mature over these last four

years. Perhaps this dissertation has given me the gift of learning how to let go, and you both the

gift of increasing independence. To my husband Tim—I know that you will say that it isn’t so,

but my accomplishments are as much yours as they are mine. You are a fantastic partner. Thank

you for filling in all the gaps without once complaining. And as a bonus, you have become a

tremendous cook! Your genuine interest and belief in the value of my work has fueled me during

the times I have wanted to give up. You are an undeserved gift!

!.

This research was supported by:

The Versant Center for the Advancement of Nursing through the VCAN® Scholars Grant.

.

Abstract

Communication is one of the key causes of healthcare-related harm. An estimated

210,000 to 400,000 deaths each year in the United States are attributed to healthcare-related

harm. Interprofessional communication and collaboration have been identified as critical to

providing safe care. Documentation is intended to support interprofessional communication and

collaboration. However, research has demonstrated that documentation in the electronic health

record (EHR) is not regularly used to support interprofessional communication. Previous

research has examined the use of the patient record for information sharing and has identified

several barriers that inhibit its use for communication; yet, little is known regarding how the

record ought to be used for interprofessional communication.

Healthcare-associated infections (HAI), including central line associated-blood stream

infections (CLABSI), is one category of healthcare-associated harm. The purpose of this study

was to describe, using the Delphi technique, what an expert panel of nurses and physicians

believe regarding how the EHR ought to be used to optimize interprofessional communication in

central venous catheter (CVC) management and prevention of CLABSI. The study was guided

by the frameworks of Distributed Cognition and Coiera’s Communication Space.

The expert panel consisted of six nurses and four physicians from a large academic

healthcare system who had experience caring for patients with CVCs and using the EHR for

retrieving, documenting, and communicating information. The panel members held such

positions as staff nurse, nurse leader, resident, attending, and physician leader/medical director.

Four Delphi rounds, which included an initial individual interview followed by three survey

rounds, were completed to achieve stability in panel member responses.


.!

The panel identified 12 information types necessary for decisions regarding whether to

keep or discontinue a CVC, the best channels for communicating each of the information types,

and factors that promote or inhibit the use of the EHR for interprofessional communication.

The findings have implications for the creation of interprofessional practice guidelines,

interprofessional education, and the development of EHRs that better support interprofessional

communication and team-based care. Understanding how to optimize the EHR in order to

leverage the knowledge captured in clinicians’ documentation has the potential to improve

patient care and reduce harm.


.!!

Table of Contents
Acknowledgements .....................................................................................................................ii

Abstract ...................................................................................................................................... v

Chapter One: Introduction........................................................................................................... 1

Background............................................................................................................................. 1

Statement of the Problem ........................................................................................................ 8

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Terms Related to Theoretical Frameworks ............................................................................ 15

Significance of the Study ...................................................................................................... 16

Chapter Two: Review of the Literature ..................................................................................... 20

Asynchronous Use of Documentation for Communication .................................................... 20

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Healthcare-associated Harm and CLABSI ............................................................................. 54

Theoretical Frameworks........................................................................................................ 59

Chapter Three: Methodology .................................................................................................... 64

Overview of Research Design and Method............................................................................ 64

Setting and Sample ............................................................................................................... 69

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Protection of Human Subjects ............................................................................................... 72

Data Collection and Data Analytic Procedures ...................................................................... 74

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Description of Sample........................................................................................................... 82

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Conclusion .......................................................................................................................... 127

Chapter 5: Discussion of the Findings ..................................................................................... 129

Summary of Findings and Discussion for Research Questions 1 and 2 ................................ 130

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Summary of Findings and Discussion for Research Questions 3 and 4: Factors that Promote or
Inhibit the Use of the EHR .................................................................................................. 138

Findings and the Theoretical Frameworks ........................................................................... 142

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Limitations of the Study ...................................................................................................... 146

Implications of the Findings for the Development of EHRs ................................................. 148

Implications of Findings for Interprofessional Practice ........................................................ 150

Implications of Findings for Interprofessional Education .................................................... 153

Recommendations for Further Research .............................................................................. 153

Conclusion .......................................................................................................................... 155

References .............................................................................................................................. 157

Appendix A- Expert Panel Criteria.......................................................................................... 176

Appendix B- Participation Request Letter ............................................................................... 177

Appendix C- Informed Consent .............................................................................................. 179

Appendix D- Interview Guide ................................................................................................. 181

Appendix E- Description of Rounds ........................................................................................ 183

Appendix F- Tentative Study Timeline ................................................................................... 186

Appendix G- Demographics Survey ........................................................................................ 187

Appendix H-Directed Content Analysis: Framework and Definitions of Predetermined Codes 190


0

Appendix I-Round 2 Survey.................................................................................................... 192

Appendix J- Round 3 Survey .................................................................................................. 212

Appendix K- Round 4 Survey ................................................................................................. 235

List of Tables .......................................................................................................................... 241

List of Figures......................................................................................................................... 242


=

Leveraging Documentation in the EHR to Support Interprofessional Communication: A Delphi

Study

Chapter One: Introduction

Communication to support interprofessional collaboration in the clinical setting is

regularly cited as one of the primary purposes of clinical documentation (American Nurses

Association, 2010; College of Nurses of Ontario, 2009; College of Registered Nurses of British

Columbia, 2007; College of Registered Nurses of Nova Scotia, 2012; Keenan, Yakel,

Tschannen, & Mandeville, 2008). The shift from paper-based records to computerized systems

or electronic health records (EHRs) has implications for how documentation is used as a means

for communication among the healthcare team (Weir et al., 2011). The ubiquitous nature of data

in the EHR has the potential to improve information sharing among all users. Yet, there is a need

for more research on how clinical documentation in the EHR is used in practice to meet

interprofessional communication needs.

Background

In 2000, The Health and Medicine Division of the National Academies of Sciences,

Engineering, and Medicine, previously known as the Institute of Medicine (IOM), estimated that

between 44,000 and 98,000 people die of preventable medical errors each year (Institute of

Medicine, 2000). A recent analysis using a more robust method for identifying healthcare-

associated harm suggests that 210,000 to 400,000 deaths occur as a result of preventable errors

(James, 2013), making healthcare-associated harm the third leading cause of death in the United

States (U. S.) (Centers for Disease Control and Prevention [CDC], 2014). These data provide an

impetus for research focusing on healthcare quality and safety. As a result, for almost two

decades, safety and quality have been at the forefront of the U.S. healthcare agenda.

>

Communication has been identified as a critical factor in the provision of safe care (IOM,

2000; James, 2013; Keenan et al., 2008; The Joint Commission (TJC), 2016). James (2013)

analyzed patient harm and identified communication as one of the five categories of preventable

adverse events. Furthermore, James (2013) attributed errors of omission, errors of commission,

errors of context, and diagnostic errors to a breakdown in communication. For example, poor

communication could result from an error of context, which is a failure to account for details

regarding a patient’s particular circumstances that may influence the efficacy of a specific

treatment plan. The failure to transmit these details, such as between a nurse and a physician, is a

failure in interprofessional communication and demonstrates how communication may be an

underlying factor in other types of error. According to TJC’s analysis of root causes for reported

sentinel events in 2015, communication was a root cause in 79% of events (TJC, 2016)—an

increase from 2013 (when it was 63%) and 2014 (when it was 64%) (TJC, 2014). TJC’s

definition of communication includes oral, written, and electronic exchanges among members of

the healthcare team and between the healthcare team and patients/families.

Communication between nurses and physicians is particularly important in terms of

patient safety due to the prominent role of these professionals in patient care (Reeves, Nelson, &

Zwarenstein, 2008; Sutcliffe, Lewton, & Rosenthal, 2004). Interprofessional communication and

collaboration have been identified as vital to the prevention of healthcare-associated harm

(Keenan et al., 2008; Leonard, Graham, & Bonacum, 2004; Zwarenstein & Reeves, 2006).

Studies have demonstrated that clinicians perceive ineffective communication and collaboration

among the healthcare team as key contributing factors in adverse events (Boev & Xia, 2015;

Manojlovich & DeCicco, 2007; Sutcliffe et al., 2004). These studies have demonstrated a

relationship between nurses’ perceptions of communication and collaboration and their impact

?

on healthcare-associated harm. They also have shown that medical residents believe that

communication failures are a substantial contributing factor to adverse events.

Manojlovich and DeCicco (2007) examined predictors of perceived patient outcomes, as

rated by nurses in intensive care units (ICUs). The study explored nurses’ perceptions regarding

hospital characteristics, workplace empowerment, nurse-physician communication, and nurses’

self-report of the occurrence of three types of adverse events: medication errors, ventilator

associated pneumonia (VAP), and catheter-associated sepsis. Results indicated that nurses’

perception of poor nurse-physician communication was a significant predictor of medication

errors (p < 0.01). In a second study, Boev and Xia (2015) conducted a secondary analysis of data

spanning 4.25 years from surveys of nurses’ (n = 671) perceptions regarding the work

environment, which included perceptions concerning nurse-physician collaboration. Boev and

Xia also collected patient outcome data on the rates of VAP and CLABSI for the study units

during the same period. They found that in critical care units, where nurses’ perception of nurse-

physician collaboration was high, rates of VAP and CLABSI were lower (p = 0.005). These two

studies indicate that nurses’ negative perceptions regarding nurse-physician communication and

collaboration are associated with a higher occurrence of adverse events.

In a qualitative study, Sutcliffe et al. (2004) explored medical residents’ perceptions

regarding communication among the healthcare team and healthcare-associated harm. The

researchers found that of the 70 incidents reported by the medical residents, communication

(both written and oral) was cited as the key factor in 28 (40%) of the incidents (Sutcliffe et al.,

2004). Further analysis revealed that even when communication was not cited as a contributing

factor, flawed communication was in some way related. Therefore, the researchers concluded

that 61 of the events (91% of incidents) were somehow related to communication failures

@

(Sutcliffe et al., 2004). One theme from the qualitative analysis was the influence of “hierarchy

and social structure” on communication (p. 192). Specifically, nurses sometimes were reluctant

to raise concerns because they felt that physicians were not always receptive to their input. The

authors also noted that good communication between the medical residents and nurses was vital

due to the critical roles of these two healthcare groups in providing patient care. Additionally,

Sutcliffe and colleagues found that in some cases written communication was not effective, and

therefore, they suggested that clinicians needed to select the appropriate channel to relay a

particular message efficiently. These three studies (Boev & Xia, 2015; Manojlovich & DeCicco,

2007; Sutcliffe et al., 2004) demonstrate that both nurses and physicians perceive communication

and collaboration as critical to providing safe care and that lack of good communication

contributes to adverse events.

Communication can occur in a synchronous or asynchronous manner across various

channels (Coiera, 2000). Examples of synchronous channels include face-to-face encounters and

telephone conversations (Parker & Coiera, 2000). Examples of asynchronous channels include

written notes, both on paper and in a computerized system, and voice mail messages (Parker &

Coiera, 2000). Current research on the exchange of information demonstrates that clinicians

commonly prefer face-to-face communication and do not regularly use a formal information

source such as the patient record when seeking patient information (Brown, Borowitz, &

Novicoff, 2004; Coiera, Jayasuriya, Hardy, Bannan, & Thorpe, 2002; Coiera, 2000; Collins,

Bakken, Vawdrey, Coiera, & Currie, 2011; Hripcsak, Vawdrey, Fred, & Bostwick, 2011). Face-

to-face or oral communication is important because it provides opportunity for clarification and

achieving shared understanding; however, it is prone to many potential problems. First,

synchronous communication between nurses and physicians is not always possible or may be

A

limited in many settings due to the mobility of clinicians during the work day (Coiera, 1996;

Street & Blackford, 2001; Zwarenstein, Rice, Gotlib-Conn, Kenaszchuk, & Reeves, 2013). Even

when synchronous communication is possible, interruptions can occur, which can further

contribute to medical errors and inefficiencies (Alvarez & Coiera, 2006; Coiera & Tombs, 1998;

Coiera et al., 2002; Coiera, 1996; Edwards et al., 2009). In a study of inter-clinician

communication, Edwards and colleagues (2009) found that all observed interruptions were due

to synchronous communication, with nurses and physicians receiving the most number of

interruptions. Other issues with face-to-face communication include information loss from oral

exchanges that commonly are not documented in the EHR (Collins et al., 2011; Conn et al.,

2009; Keenan, Yakel, Lopez, & Tschannen, 2013; Street & Blackford, 2001), the influence of

hierarchy or power differentials between the nurse and physician (Rowlands & Callen, 2013;

Sutcliffe et al., 2004; Zwarenstein et al., 2013), and the resultant underrepresented view of the

nurse during oral exchanges (Rowlands & Callen, 2013; Weber, Stöckli, Nübling, & Langewitz,

2007; Zwarenstein et al., 2013). As such, it is important to understand when a synchronous or

asynchronous channel is most effective to accomplish a particular communication task, and how

to leverage documentation in the EHR to overcome issues related to synchronous exchanges

(Coiera & Tombs, 1998; Sutcliffe et al., 2004).

Studies have begun to demonstrate the significance of the information documented by the

nurse in regards to patient outcomes (Chang, Rubenstein, Keeler, Miura, & Kahn, 1996; Collins

et al., 2013; Rothman, Solinger, Rothman, & Finlay, 2012), further emphasizing why it is

important for other healthcare professionals to use nursing documentation to inform clinical

decisions and guide patient care. Chang et al. (1996) conducted a secondary data analysis to

examine the validity of nursing assessments and surveillance in predicting admission to ICUs

B

versus non-ICUs. The sample (n = 11,246) consisted of patients with acute myocardial infarction

(MI), cerebrovascular accident (CVA), congestive heart failure (CHF), or pneumonia (Chang et

al., 1996). The researchers used the nursing assessment and monitoring of signs and symptoms

scale (NAMSS) as a measure of nursing care processes. This study found that NAMSS scores

were significantly higher for those admitted to the ICU (p ≤.01), demonstrating that the medical

record–based review supported the validity of the NAMSS indicators that are reflective of

nursing assessments (Chang et al., 1996).

A more recent study by Rothman et al. (2012) demonstrated the validity of nursing

assessments in accurately conveying the changing patient condition. The authors analyzed data

collected in the EHR for all inpatient visits (n = 42,302) in an 805-bed community hospital for

two 1-year periods, excluding obstetrics, pediatric, and psychiatric patients. The results

demonstrated that abnormal findings in nursing assessments, in all categories except pain, were

significantly associated with increased risk for mortality (ORs ranging from 2.3 to 9.4; p < .001).

Furthermore, abnormal findings on nursing assessments conducted prior to discharge were

significantly associated with increased risk for post-discharge mortality at 30 days (ORs ranging

from 3.1 to 16; p < .001). Although this may seem self-evident to nurses, this study demonstrated

a statistically significant relationship between assessment data recorded by nurses and resultant

patient outcomes. Rothman et al. (2012) concluded that nursing assessment data are dynamic due

to nurses’ continuous contact with patients in the acute care setting, thereby providing an

indication of risk for individual patients. Another important point raised by the authors is that the

documented data from nursing assessments are underutilized.

A third study that examined nurses' EHR documentation also concluded that this

information was predictive of patient outcomes (Collins et al., 2013). This study used data

C

mining techniques to examine a sample of acute care patients (n = 15,000) and cardiac arrest

patients (n = 145). Collins et al. (2013) found that an increased frequency of optional

documentation by nurses was significantly associated with an increased frequency of cardiac

arrest, independent of the patient’s condition (p < .001). Similarly, there was an increased

frequency of documentation of vital signs, beyond what was required, for patients who

experienced cardiac arrest (p < .01). These authors discussed the potential for using nursing

documentation to predict patient risk, noting that “perhaps current risk scores remain inadequate

to predict patients' outcomes because they do not account for the knowledge in a nurse's

assessment” (Collins et al., 2013, p. 311). All three of these studies demonstrate that nursing

documentation accurately identifies risk; as such, it is logical to conclude that reading and using

nursing documentation may contribute to a reduction in patient harm.

How information is shared between the nurse and the physician is an important area for

research, particularly as it relates to patient outcomes. Research demonstrates that nursing

documentation exhibits nursing concern and is associated with patient outcomes (Chang et al.,

1996; Collins et al., 2013; Rothman et al., 2012). However, research has shown that clinicians

minimally use the patient record when seeking patient information (Brown et al., 2004; Coiera et

al., 2002; Collins et al., 2011; Hripcsak et al., 2011). This warrants our attention, supporting a

need for further research on how the record could be used to support interprofessional

communication. Qualitative studies have examined the use of the patient record for information

sharing and have identified several barriers that inhibit its use for communication in its current

state (Collins et al., 2011; Embi et al., 2013; Gilardi, Guglielmetti, & Pravettoni, 2014; Keenan et

al., 2013; Kossman & Scheidenhelm, 2008; Rowlands & Callen, 2013; Street & Blackford, 2001;

Varpio, Schryer, & Lingard, 2009). However, little is known regarding how the record ought to

D

be used or best practices to guide its use for interprofessional communication. The Delphi

technique is a method used to illicit expert opinion regarding complex issues. Therefore, it can

be applied to explore how the EHR should be used to support interprofessional communication

between nurses and physicians. Due to the key contribution that communication plays in patient

safety, understanding how documentation in the EHR can support interprofessional

communication has the potential to decrease healthcare-related harm.

Statement of the Problem

The literature suggests that the EHR documentation is not regularly used to support

interprofessional communication. Furthermore, there is no expert consensus on how

documentation in the EHR can best support interprofessional communication in the acute care

setting. Exploration of what ought to be communicated between the nurse and the physician

through the EHR is needed to guide its configuration so that it can support interprofessional

communication and reduce healthcare-associated harm.

Although there are many categories of healthcare-associated harm, healthcare-associated

infections (HAIs) are a primary concern. Magill et al. (2014) estimate that in 2011, 648,000

patients acquired 721,000 HAIs. Of these 721,000 infections, an estimated 25.6% were related to

medical devices, such as CVCs (Magill et al., 2014). TJC identified the reduction of HAIs, with

a specific focus on CLABSI, as one of the national patient safety goals for 2015 (TJC, 2015); the

prevention of CLABSI continued to be a national patient safety goal in 2016 and 2017 (TJC,

2017). Mortality rates from CLABSI are 12 to 25% (CDC, 2011). Furthermore, increased length

of stay and increased costs related to CLABSI have negative implications for patients.

In light of these statistics, it is important to note that CLABSIs are largely preventable.

Umscheid et al. (2011) conducted an analysis to determine the number of “reasonably


E

preventable” HAIs (p. 101). The term, reasonably preventable, signifies that there are identified

strategies that can successfully reduce the likelihood of infection. Umscheid et al. quantified the

term by examining the results of studies reported to the Agency for Healthcare Research and

Quality (AHRQ) and calculating the reduction in infection rates after the implementation of an

intervention strategy. They found that CLABSI was associated with 44,762 to 164,127

preventable infections and the highest number of preventable deaths among all HAIs (Umscheid

et al., 2011, p. 103).

There are well-established guidelines for the prevention of CLABSI, including shortening

catheter dwell time with prompt removal of non-essential lines (Association for Professionals in

Infection Control and Epidemiology [APIC], 2015). Reducing catheter dwell time requires an

understanding of a patient’s current condition and projected course; therefore, it is dependent on

effective communication among the interprofessional team. The study presented here specifically

examined CLABSI and the use of documentation to support interprofessional communication

regarding the management of CVCs and the prevention of CLABSI.

Purpose of the Study

To describe, using the Delphi technique, what nurses and physicians believe regarding

how the EHR ought to be used to optimize interprofessional communication concerning CVC

management and the prevention of central line–associated blood stream infections (CLABSIs).

Research Questions

i. What type of information is best communicated asynchronously through documentation in

the EHR between nurses and physicians regarding the prevention of CLABSI in patients

with central venous catheters (CVCs)?


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ii. What type of information necessitates synchronous oral communication between nurses

and physicians regarding the prevention of CLABSI in patients with CVCs?

iii. What are the factors that inhibit asynchronous communication through documentation in

the EHR between nurses and physicians regarding the prevention of CLABSI in patients

with CVCs?

iv. What are the factors that promote asynchronous communication through documentation in

the patient record between nurses and physicians regarding the prevention of CLABSI in

patients with CVCs?

Definition of Terms

Communication: oral, written, and electronic exchanges among members of the healthcare team,

with administration, and between the healthcare team and patients/families (TJC, 2016).

Interprofessional communication: communication that occurs between two or more members of

different professional groups involved in the provision of patient care. In this study, the

professional groups included nursing and medicine, more specifically registered nurses (RNs)

and physicians.

Asynchronous communication: describes any type of communication that does not require the

individuals to participate in the exchange at the same moment in time (Coiera et al., 2002; Conn

et al., 2009). This involves the use of asynchronous channels, such as email, recorded voice

messages, or documentation in the patient record. For this study, the concept of interest is

asynchronous communication through the EHR.

Synchronous communication: describes communication that occurs when both individuals are

present at the same moment in time during the exchange (Coiera et al., 2002; Conn et al., 2009).

For example, this can occur via a channel that supports synchronous exchanges from a distance,

==

such as a telephone, and also through impromptu face-to-face discussions or scheduled meetings

such as interprofessional rounds.

Electronic Health Record (EHR): A computerized system used “for purposes of setting

objectives and planning patient care, documenting the delivery of care and assessing the

outcomes of care. It includes information regarding patient needs during episodes of care

provided by different healthcare professionals” (Häyrinen, Saranto, & Nykänen, 2008, p. 292). A

basic EHR should include the following functionalities: patient demographics, physician notes,

nursing notes, nursing assessments, problem lists, medication lists, discharge summaries,

laboratory reports, radiologic reports, diagnostic test results, and computerized provider-order

entry of medications (Jha et al., 2009).

Theoretical Frameworks

The development of computerized documentation systems in the absence of theory

regarding communication and collaborative work may result in systems that are inept at

supporting these complex processes (Weir et al., 2011). Providing increased access to copious

amounts of information, by way of computerized information systems, does not in itself improve

interprofessional communication and collaboration effectively. Distributed cognition provides a

framework for examining the cultural norms or rules that influence interactions of people

("human actors") and the use of artifacts (EHRs) to achieve shared understandings (Hazlehurst,

Gorman, & McMullen, 2008) (see Figure 1). In addition, Coiera’s communication space

framework explains the influence of common ground on communication via computerized

systems (Coiera, 2000) (see Figure 2).

 =>

Figure 1. Visual Model for Distributed Cognition Including the Concept of Common

Ground
 =?

Figure 2. Influence of Common Ground on Use of a Synchronous or Asynchronous

Channel

Hazlehurst (2015) defined distributed cognition as “a theory of human cognition that

describes how information processing is distributed across people and their workplace (situated

teams), their technologies (tools), and their social organization and its influences through time

(culture)" (p. 755). Distributed cognition is distinctive from traditional cognitive science in that,

rather than studying cognition from the perspective of the individual and that individual's

interactions with a system, the unit of analysis is the system itself (Hutchins, 2014). This unit of

analysis is commonly referred to as the activity system (Hazlehurst et al., 2008; Hazlehurst,

Mcmullen, & Gorman, 2007; Hutchins, 2014). Cognition is defined as “the mental action or

=@

process of acquiring knowledge and understanding through thought, experience, and the senses

(“cognition”, n.d.)”. Communication is defined as “the imparting or exchanging of information”

with the aim of shared understanding (“communication”, n.d.). In distributed cognition, “the

process of acquiring knowledge and understanding” (cognition) is dependent on the interaction

of elements within the activity system, which involves “the imparting or exchanging of

information” (communication) and results in the formation of “representational states” that are

derived from particular elements in the system. A representational state signifies the structures

that convey the information (Hazlehurst et al., 2008). This could include how artifacts (tools)

display information or actual phrases communicated between two individuals. For the purposes

of this study, the activity system includes nurses and physicians (human actors), the EHR (the

artifact), and the norms or rules that guide the interactions and communications among all three

when managing a CVC with the aim of preventing CLABSI. This study explored

representational states, such as how information is displayed in the EHR or what is orally

communicated.

Coiera (2000) uses the phrase “communication space” to describe the sharing of

information among clinicians in the healthcare system. In some aspects, this is similar to the

activity system in distributed cognition because it is reflective of the interactions among

individuals as well as the channels by which, or across which, information is shared. However,

Coiera asserts that the most significant aspect of the communication space is the direct

exchanges among the clinicians themselves, suggesting that informatics tools should conform to

meet the clinicians' needs instead of clinicians adapting their communication practices to fit

within the available informatics tools (Coiera, 2000, 2015). Furthermore, Coiera emphasizes the

influence of common ground on communication particularly as it relates to informatics tools and


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the use of synchronous or asynchronous channels. Common ground represents the “knowledge

shared by two communicating agents” (Coiera, 2000, p. 282). According to Coiera,

communication tasks exist on a continuum—the exchange of information asynchronously

represents one end of the continuum and synchronous communication tasks represent the other

(see Figure 2). Common ground between participants and/or tools (artifacts) influences where

along the continuum a communication task will be accomplished successfully. Coiera (2000)

stated, “the continuum view aims to understand which specific task characteristic would indicate

where along the technologic continuum we look for solutions” (p. 279). Coiera further asserts

that building common ground requires a cost on behalf of the participant, and that a participant

will take what is perceived to be the least costly approach when seeking to access or exchange

information (Coiera, 2003). If communicating through an asynchronous channel such as the EHR

requires effort to develop common ground ahead of time (preemptive grounding), then the

clinician will demonstrate a bias for synchronous conversations, which requires less grounding

before the interaction. Both the theory of distributed cognition and Coiera’s communication

space, including the information-communication continuum, provided a framework for exploring

what information should be communicated synchronously versus asynchronously and the factors

that promote or inhibit asynchronous communication via the EHR.

Terms Related to Theoretical Frameworks

Distributed cognition: “is a theory of human cognition that describes how information

processing is distributed across people and their workplace (situated teams), their technologies

(tools), and their social organization and its influences through time (culture)” (Hazlehurst, 2015,

p. 755).

=B

Activity system: “An activity system comprises a group of human actors, their tools and

environment, and is organized by a particular history of goal-directed action and interaction”

(Hazlehurst et al., 2008, p. 228).

Representational state: “is a particular configuration of an information-bearing structure, such as

a monitor display, a verbal utterance, or a printed label that plays some functional role within a

process” (Hazlehurst et al., 2008, p. 228).

Communication space: the interactions between healthcare professionals that involve the sharing

and interpretation of information to make clinical decisions (Coiera, 2000).

Common ground: “knowledge shared by two communicating agents” (Coiera, 2000, p. 282).

Grounding: the act of establishing common ground (Coiera, 2000). This can involve the sharing

of cultural norms or behaviors particular to a professional role for clinicians, or common

understandings about rules and expectations of another based on past experiences. Grounding

can also occur between an individual and an informatics tool as a result of competence with

using the particular tool due to training and/or experience (Coiera, 2003).

Significance of the Study

This study has significance for interprofessional practice, interprofessional education, and

applied health informatics. In clinical practice, clinicians adapt and create workarounds to make

technology conform to their needs (Embi et al., 2013; Gilardi et al., 2014; Kossman, Bonney, &

Kim, 2013). This process can result in work practices that contribute to healthcare-associated

harm (Coiera, 2015). Although it is important to ensure that technology supports care practices,

it is equally important that care practices are based on evidence-based standards when available.

Communication has been implicated as a key factor in adverse events that result in healthcare-

associated harm. Identifying best practices for communicating through the EHR requires moving

=C

beyond the study of existing behaviors to research designed to seek out opinions from expert

clinicians themselves on when, where, and how to communicate key information. Such research

could be used to develop standards and policies that guide communication practices.

Resultant communication standards and practices also should be used to inform nursing

and interprofessional education. In their Ten Trends to Watch, the National League for Nursing

cites “the technological explosion” and “the growing need for interdisciplinary education for

collaborative practice” as important areas in the future of nursing education (Heller, Oros, &

Durney-Crowley, 2000). Both of these topics are closely related to the issue of interprofessional

communication through documentation in the EHR. Furthermore, interprofessional education has

been identified as an important initiative to address communication issues and care coordination

(IOM, 2001, 2013; Robert Wood Johnson Foundation, 2011).

In the Core Competencies for Interprofessional Collaborative Practice, the first

competency listed under interprofessional communication is the selection of “effective

communication tools and techniques, including information systems and communication

technologies, to facilitate discussions and interactions that enhance team function”

(Interprofessional Education Collaborative Expert Panel, 2011, p. 23). In their review of new

graduates’ experiences with interprofessional collaboration, Pfaff, Baxter, Jack, and Ploeg (2014)

emphasized the importance of understanding the roles of those who comprise the healthcare team

and knowing what information is vital to share with the team. Results from this study provide

insight regarding what information to share and the appropriate channel to use to most

effectively accomplish a communication task that supports CVC management. Interprofessional

education must include how to effectively leverage technology to support safe care through

collaborative practice. Interprofessional courses that include what information each profession

=D

considers essential and what can be exchanged through the record is critical in supporting

interprofessional work. Developing a shared understanding of what and how healthcare team

members document has the potential to influence better communication through the EHR. Such

changes in how the interprofessional team communicates are dependent on the formation of

values learned in the early days of a clinicians’ education. Solutions aimed at changes in practice

are extremely important; however, it is also vital to understand how interprofessional education

can influence practice before a patient is harmed.

Lastly, this study has significance for applied health informatics to advance the methods

used to guide the configuration of EHRs that support interprofessional communication. Coiera

(2000) contends that informatics tools should meet the needs of practicing clinicians, and the

IOM has encouraged a collaborative approach to the development of EHR systems so that they

better support team-based care (IOM Committee on Patient Safety and Health Information

Technology, 2012). Past research has shown that clinicians do not believe that the design of

existing EHR systems support interprofessional collaboration (Bardach, Real, & Bardach, 2017;

Embi et al., 2013; Keenan et al., 2013). This study is among those that seek to understand the

factors that promote or inhibit the use of documentation as well as what types of information can

be shared effectively via documentation to help guide the development of EHR systems that

support communication between nurses and physicians. This study used the Delphi technique to

identify and seek consensus on “best practices” for exchanging vital patient information and the

EHR's role in this communication; in addition, it addressed the call for a collaborative approach

to EHR system development. Thus, the methodological approach of this study and its specific

findings on the best use of synchronous and asynchronous channels provide the needed evidence

=E

to guide the configuration and use of EHRs to optimally support interprofessional

communication.

This study explored the use of documentation in the EHR in the context of the

management of CVCs and CLABSI prevention using the Delphi technique. Replicating this

study method in other contexts could aid in the formation of “best practices” for information

sharing and EHR systems design to facilitate interprofessional communication. Such efforts have

the potential to reduce patient harm resulting from communication failures.

This study addresses the need for more research to understand how to maximize the use

of documentation in the EHR to promote interprofessional communication and takes the next

important step— to achieve consensus among nurses and physicians regarding what information

is considered critical to share between the professions, what information is vital to document in

the EHR, how to share the information, and what necessitates a synchronous oral exchange. This

requires both nurses and physicians to examine their documentation and communication

practices, and to consider how these practices support interprofessional communication.

Increased understanding of one another’s roles, which may be achieved through interprofessional

education, should augment these efforts. Furthermore, EHRs must be tailored to facilitate

interprofessional exchanges that aid in developing a shared understanding of the patient, and

health information technology should enhance the quality and safety of healthcare. To achieve

these goals, input from all healthcare professionals is needed when designing and structuring

systems used to document and communicate care.


><

Chapter Two: Review of the Literature

Safe patient care is dependent on effective communication among the healthcare team

(IOM, 2000; James, 2013; TJC, 2016). To promote patient safety, documentation in the patient

record should facilitate the exchange of information to support communication (American

Nurses Association, 2010; College of Nurses of Ontario, 2009; College of Registered Nurses of

British Columbia, 2007; College of Registered Nurses of Nova Scotia, 2012; Keenan et al.,

2008). However, there is a paucity of research with specific evidence on how documentation in

the EHR can enhance communication between the nurse and the physician. To provide

background for the study, three areas of literature relevant to how documentation in the EHR

should be used for interprofessional communication were reviewed. These included: (1) the

asynchronous use of documentation, including frequency, patterns, and purposes of use; (2)

synchronous oral communication between nurses and physicians and related issues; and (3)

factors that promote or inhibit the use of the EHR for communication. A discussion of literature

related to CLABSI, one category of healthcare-related harm that served as the context for this

study, follows. Lastly, literature on the theory of distributed cognition and Coiera’s theoretical

framework of clinical communication space is presented.

Asynchronous Use of Documentation for Communication

The majority of studies that have examined the asynchronous use of documentation are

based on the premise that one of the primary purposes of documentation is communication

(Brown et al., 2004; Hripcsak et al., 2011; Liu, Manias, & Gerdtz, 2014; Penoyer et al., 2014;

Törnvall & Wilhelmsson, 2008). However, several studies demonstrate that in clinical practice,

documentation is minimally used as a means of communication, particularly among members of

different professional groups (Brown et al., 2004; Coiera et al., 2002; Hripcsak et al., 2011;

>=

Penoyer et al., 2014; Törnvall & Wilhelmsson, 2008). A small body of research has

demonstrated the effectiveness of specialized documentation in supporting interprofessional

communication (Agarwal, Frankel, Tourner, McMillan, & Sharek, 2008; Phipps & Thomas,

2007; Pronovost et al., 2003). The studies in this section have been sub-divided into three

categories: the frequency of use of asynchronous documentation, the patterns of use and related

purposes, and the use of specialized forms.

Frequency of Use of Asynchronous Documentation

Three studies explored how frequently asynchronous channels are used, including what

aspects of asynchronous documentation are used most often (Brown et al., 2004; Coiera et al.,

2002; Hripcsak et al., 2011). Coiera et al. (2002) conducted an observational study to measure

communication loads and the pattern of informal and formal communication events for nurses (n

= 6) and physicians (n = 6) in two emergency departments (EDs) (p. 415). They found that over

the course of the observation, nurses and physicians were involved in communication tasks for

28 hours and 12 minutes (80% of the time). Of the time spent communicating, only a small

portion of the time (12.3%) was spent accessing a formal information source, such as the patient

record (Coiera et al., 2002). As a result, the majority of communication and information

exchange was accomplished through face-to-face conversation (82%). It is not clear from the

description of this study whether the record was a computerized system, such as an EHR or a

paper based system.

Brown et al. (2004) developed a survey to describe the oral and written sources

physicians reported using when seeking patient information in a neonatal intensive care unit

(NICU). Findings indicated that physicians (residents n = 15, faculty n = 31) preferred the

bedside flow sheet (mean 1.5, 95% CI [1.0, 2.0]), conversations with residents (mean 1.4, 95%

>>

CI [0.9, 1.9]), and conversations with nurses (mean 1.1, 95% CI [0.6, 1.8]). The least used

information sources for physicians were admission notes and daily notes written by residents and

faculty. These results suggest physicians’ preference for summarized data, as presented in flow

sheets, and the predominant use of face-to-face communication.

Hripcsak et al. (2011) examined usage logs from an EHR that showed “user identity, note

type, and time spend viewing the note” to quantify the use of documentation among clinical

teams (p. 112). Methods for this study consisted of totaling the time spent writing notes and the

use of notes by various groups within an inpatient area of an academic medical center (Hripcsak

et al., 2011). In addition, the authors performed social network analysis to explore the

relationships between those authoring and those viewing notes. Results revealed that over a 3-

month period, nursing notes were read infrequently. The percent of nursing notes read averaged

20% by physicians and 38% by nurses (Hripcsak et al., 2011). In addition, physicians read more

notes written by those within their discipline than the notes written by nurses. When analyzing

team interactions, the authors reported that communication through documentation was greater

within groups (for example, nurse to nurse or physician to physician) than between groups. A

strength of this study is that the analysis of actual documentation use included time spent both

writing and viewing notes, by whom, and for how long, versus self-reported use.

Evidence from all three of these studies highlights the limited use of documented

information for communication regardless of the setting or type of clinician. One study did find

that membership in the same discipline increased information sharing through documentation

(Hripcsak et al, 2011), which is consistent with Coiera’s concept of common ground and how it

influences the use of asynchronous communication channels. Brown et al. (2004) and Hripcsak

et al. (2011) also provide insight into which aspects of documentation are preferred. However, a

>?

key limitation of the study by Brown et al. is that the survey did not include the nurses’ note as

an information source; it included only notes written by attending physicians and residents. A

limitation of the study by Hripcsak et al. was that only free text notes were included in their

analysis, thus excluding nurses' flow sheet documentation, which includes clinical data such as

vital signs, fall assessments, and intake and output. The authors acknowledged this deficiency

and reported that it was due to the “way they [flow sheets] are incorporated into the application

[EHR]” (Hripcsak et al., 2011, p. 117). As a result of this limitation, a significant portion of

nursing documentation was not included in the study. This is problematic because in many

settings, much of what the nurse documents is done in flow sheet format such as vital signs,

intake and output, and shift assessments. As in the study by Brown et al., other studies have

described a preference for this type of summarized information in the EHR (Collins et al., 2011;

Törnvall & Wilhelmsson, 2008).

Patterns of Use of Asynchronous Documentation and Related Purposes

Several studies examined the frequency of use but also described purposes for seeking

documented information. Törnvall and Wilhelmsson (2008) investigated “the utility of nursing

documentation with respect to communication” in primary healthcare centers in three country

councils in Sweden (p. 2118). This cross-sectional descriptive study had a dual focus: first, to

determine the extent and purpose of electronic nursing documentation use by general

practitioners (physicians) and second, to examine the use of documentation by care unit mangers

(typically nurses) for quality improvement. Separate questionnaires were developed for general

practitioners (GP) (n = 430) and care unit (CU) managers (n = 74) and tested for content and face

validity. The researchers distributed the questionnaires via mailings with an impressive response

>@

rate of 79% for GPs. Data analysis included descriptive statistics for closed-ended questions and

content analysis for open-ended questions.

Results indicated that 58% of GPs “always or often” read the nursing documentation

(Törnvall & Wilhelmsson, 2008). GPs reported that they sought information about treatment

follow-up most frequently (80%), followed by information related to the patient’s status

(approximately 70%) (Törnvall & Wilhelmsson, 2008). Information regarding the patient’s

subjective experiences (31%) was the least sought category of information. Although the authors

reported more frequent use of nursing documentation than the aforementioned studies, the

content analysis revealed that GPs felt that nursing documentation “lacked structure” and was

missing key information related to patient assessment (Törnvall & Wilhelmsson, 2008, p. 2120).

These findings contradict results from the questionnaire in which 83% of GPs reported that they

found the information they were looking for in nursing documentation. The authors noted this

contradiction and suggested modifications to the question aimed at this concept. This merits

further investigation; if the records do not contain information needed about patients, then the

records would not support improved interprofessional communication even if it were used.

Another key finding from the content analysis was the theme that good documentation could not

(or perhaps should not) replace face-to-face discussions (Törnvall & Wilhelmsson, 2008). This

finding supports the present study that aimed to explore what information should be documented

in the record to support interprofessional communication and what information necessitates face-

to-face exchanges.

Kossman et al. (2013) sought to describe how nurses (survey respondents n = 33, focus

group n = 4, total n = 37) from both the ICU and medical/surgical unit of a tertiary care medical

center used tools or cognitive artifacts, including the EHR, to support clinical judgment and team

>A

communication. In a previous study, they found that nurses preferred the EHR to paper

documentation, but the nurses also felt that the EHR hindered communication between nurses

and physicians (Kossman & Scheidenhelm, 2008). The researchers used a descriptive convergent

mixed-method design (Kossman et al., 2013), in which they collected both qualitative and

quantitative data simultaneously and used both equally to inform the analysis (Creswell, 2003).

Data collection included retrieval of usage statistics from the EHR for only 1 day; this brief time

period is a limitation in the study. The groups of healthcare professionals included in the review

of usage statistics were nurses, nurse practitioners, physicians, pharmacists, dietitians, social

workers, physical therapists, occupational therapists, speech pathologists, and pastoral care.

Descriptive statistics of actual use revealed that all healthcare professionals viewed EHR tools

frequently for interdisciplinary “summary notes” and flow sheets. In addition, the researchers

reported that all of the healthcare professions, excluding physicians and pharmacists, viewed the

care plan (Kossman et al., 2013). For nurses, the three most frequently used tools in rank order

were flow sheets, the MAR, and the summary notes (Kossman et al., 2013). Because members

from the other health professions viewed summary notes and care plans, the researchers

suggested that perhaps these tools are useful for team communication.

In addition to collecting usage data, Kossman et al. (2013) sent an online survey to a

convenience sample of 50 nurses in a tertiary care medical center working on ICU or medical-

surgical floors who had at least 6 months experience with the EHR system. The response rate

was 66% (n = 33). Survey results indicated that nurses rated self-made worklists and MARs as

“extremely useful” in supporting team communication (Kossman et al., 2013, p. 541).

Qualitative data from focus groups revealed that although nurses (n = 4) reportedly obtained

information from the EHR for their self-made worklists, the informal tool allowed them to

>B

organize and access data in way that supported their work, thus exposing the inability of the

EHR to do so. When asked how EHRs could better support their clinical judgment and team

communication, nurses could not provide an answer, stating that they just adapt to what is

provided to them (Kossman et al., 2013). This finding has implications for how to solicit

information from nurses regarding their information needs. Focusing more specifically on why

particular tools or artifacts are more useful than others and what information clinicians believe is

critical to be shared with the team, may provide insight regarding EHR development.

Penoyer et al. (2014) conducted a descriptive exploratory study utilizing an online survey

to ascertain what parts of the EHR are viewed for what purposes, including clinicians’

perceptions regarding time spent creating and reviewing documentation. A study strength was

the larger sample size (n = 700) and the inclusion of various clinicians (prescribers, nurses, and

ancillary staff) from six different community hospitals (Penoyer et al., 2014). Findings revealed

that the items viewed most frequently were the diagnostic results, physicians’ orders, the

physician-recorded histories and physicals, and physicians’ notes; items viewed less frequently

(particularly by prescribers) included nursing assessments and the care plan. This is in contrast to

the aforementioned findings by Kossman et al. (2013) who reported the use of summary notes

and care plans by other health professionals; however, the Kossman study does not distinguish

who authored the summary notes and care plans. If the summary notes and care plans are

interdisciplinary documents, this has different implications than if they are authored solely by

nurses because Penoyer et al. found that nursing documentation is used infrequently by the

healthcare team. Findings by Penoyer et al. revealed an emphasis on the use of information

generated by those in the medical profession as opposed to nursing; and these findings were

consistent across roles, including both prescribers and bedside nurses. A key methodological

>C

difference in these two studies was that Kossman et al. used actual usage statistics—albeit from 1

day—while Penoyer et al. relied on self-report.

Several studies have described the reasons for which health professionals seek

information documented in the EHR. Penoyer et al. (2014) found that prescribers and bedside

nurses most commonly reported using information for making clinical decisions concerning

patients. Of note, use of information in the EHR commonly was described as useful for

communication and collaboration, yet only 38% of respondents reviewed nursing documentation,

regardless of their healthcare role. This finding is consistent with those reported by Hripcsak et

al. (2011). This has implications for effective interprofessional communication and implies that

information documented by nurses is not used regularly for making clinical decisions. One

explanation for the infrequent use of nursing documentation by prescribers was the lack of

awareness regarding this information, including where it could be found and the lack of clinical

summaries (Penoyer et al., 2014).

Liu et al. (2014) utilized a critical ethnographic approach to explore how medication

documentation is used in interprofessional communication, including the issues of “knowledge”

and “power relations” (p. 247). Although this study had a more narrow focus, relevant

information related to patterns of and purposes for use of documentation are described. Various

ethnographic methods were used to collect data that incorporated observation, interviews, video-

recordings, review of documentation, and reflexive focus groups (Liu et al., 2014). It is

noteworthy that focus groups were not conducted with physicians or pharmacists due to

challenges with gathering professionals from these groups; therefore, focus groups consisted of

nurses only (Liu et al., 2014).


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Results were discussed according to four themes: “Lost knowledge: The issue of the ‘stat

order,” “Hidden knowledge: Nurses’ scrutiny on medication charts,” “Distinctive knowledge:

Pharmacists making recommendations,” and “Devalued knowledge: Nurses’ voice through

documentation” (Liu et al., 2014, p. 253-255). The first theme reflected a need for oral (or

synchronous) communication regarding particular aspects of medication management (for

example, stat orders). The second described the important, yet under-recognized role of nurses in

ensuring the correctness of medication orders. The third theme highlighted pharmacists’ use of

and preference for communication though documentation. The authors reported that pharmacists

exhibited this preference due to their desire to avoid confrontation (Liu et al., 2014), which

implies that documentation may be used to circumvent issues with power differentials. This

concept of communicating through documentation to avoid confrontation is explored further in

this chapter (see section on synchronous communication and the related consequences). Lastly,

the fourth theme exposed the dominance of the biomedical perspective in healthcare, whereby

the narrative dialogue recorded by nurses in progress notes, which included subjective data from

patients, was not viewed as critical to patient care (Liu et al., 2014). This last point is salient to

this Delphi study. Other researchers have demonstrated that what the nurse documents is

reflective of the patient’s changing condition (Chang et al., 1996; Collins et al., 2013; Rothman

et al., 2012). In the context of the study by Liu et al., the use of information regarding medication

administration issues and patient responses to medications captured in nursing notes was

underutilized, yet it has the potential to positively impact safety and quality in patient care. Using

the Delphi method to explore what factors inhibit the use of EHR documentation will provide

insight on how to overcome the underuse of this resource.


>E

Findings from the previously cited studies (Kossman et al., 2013; Liu et al., 2014;

Penoyer et al., 2014; Törnvall & Wilhelmsson, 2008) provide conflicting results regarding the

patterns of use and purposes for seeking documented information. However, these studies

provide additional evidence that documentation, whether in the EHR or in a paper record, is used

minimally to support interprofessional communication. The studies also further assess which

aspects of documentation are used more frequently and for what purposes. These studies add to

findings that have shown that clinicians prefer structured formats such as summary notes and

flowsheets (Brown et al., 2004; Collins et al., 2011).

Another important consideration is the different methods used for data collection in these

studies and how those methods may influence the findings. Tornvall and Wilhelmsson (2008)

and Penoyer et al. (2014) utilized self-report to collect information regarding the use of EHR

documentation. Kossman et al. (2013) also used self-report but augmented it with actual usage

data, albeit for 1 day. Liu et al. (2014) used various ethnographic methods, which allowed for

triangulation of findings, adding rigor to their study. Study designs that include both self-

reported data with rationales for sources used and type of information sought, in conjunction

with data collection tools that measure actual use and qualitative fieldwork, will provide the most

complete information regarding patterns of information sharing. However, it will also be

important to go beyond descriptions of existing patterns of use to describe best practices, due to

the clear evidence that current communication practices do not support safe care effectively. The

Delphi method would address this gap in the current research.

Use of Specialized Forms for Asynchronous Communication

A small body of research has affirmed the utility of a goals sheet in communicating

specific information related to the care plan (Agarwal et al., 2008; Phipps & Thomas, 2007;

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Pronovost et al., 2003). Other studies have been inconclusive on the usefulness of specific

documentation tools in facilitating the communication of patient information (Heffner, Barbieri,

Fracica, & Brown, 1998; Pageler et al., 2014). This section presents studies that examined the

use of specialized documentation forms to facilitate communication.

To improve patient-centered communication, Pronovost et al. (2003) developed a daily

goals form to be used to facilitate information sharing between nurses and physicians. They

conducted a prospective cohort study to evaluate the impact of a daily goals sheet on

communication in a 16-bed surgical ICU. To evaluate communication before and after the

implementation of the daily goals sheet, ICU residents and nurses were asked two questions after

daily rounds pertaining to the goals of treatment. Each day, two patients were selected randomly,

using a sampling frame based on bed number, and the corresponding primary nurse and resident

were surveyed.

Results included descriptions of length of stay (LOS) over the study period (June 2001 to

June 2002) and the understanding of goals, as stated by the residents and nurses. After

implantation of the daily goals sheet, understanding of goals increased from 10% to 95%, and

LOS decreased from a mean of 2.2 days to 1.1 days (Pronovost et al., 2003). Although the

authors concluded that this was a significant change, no p-values were reported. Another

limitation was the lack of a control group, so the decrease in LOS cannot be attributed to the

daily goals sheet alone. Moreover, the increased focus on communication may be a confounding

variable, potentially influencing perceived improvements in communication of goals.

Phipps and Thomas (2007) also investigated the impact of a daily goals sheet using a

form modified from the one Pronovost et al. (2003) used. The setting was a 12-bed medical-

surgical pediatric ICU (PICU), thus testing the use of goals sheets in a pediatric population. The

?=

researchers used a prospective, longitudinal design, comparing factors before and after

implementation of the intervention, similar to the design in the Pronovost study. However, the

secondary outcome measure of LOS was not included. The sample consisted of all members of

the PICU nursing staff before (n = 40) and after (n = 42) implementation of the daily goals sheet.

Surveys were administered to the nursing staff to measure their perception of communication.

The post implementation survey, which was completed after the 12-month implementation

period, revealed that 85% of nurses felt the daily goals sheet improved communication and

patient care.

The authors identified several limitations of the study, including response bias, the

potential Hawthorne effect, lack of measurement of physicians’ perceptions, and lack of validity

of the measurement tool (Phipps & Thomas, 2007). Response rates before and after

implementation were 65% (26/40) and 52% (22/42) respectively, which are adequate; no data on

the characteristics of the non-responders were reported. The Hawthorne effect, or the possibility

that the perception of improved communication was due to the focus placed on communication

during the study period, is similar to the issue discussed in the analysis of Pronovost et al.

(2003). Also, as the authors note, the physicians’ perception of communication was not measured

in this study, which would have provided a broader picture of the impact of the goals sheet.

Lastly, psychometrics of the survey were not reported. These limitations require consideration,

yet this study corroborates the results from Pronovost et al.’s study.

Agarwal et al. (2008) also investigated the impact of daily goal sheets on communication

among nurses and physicians in a PICU. In addition, they measured nurse’s knowledge of the

attending physician and fellow in charge of their patient as well as LOS. This longitudinal, pre-

post study was conducted in a 12-bed PICU in a teaching hospital associated with Stanford

?>

University. Questionnaires, using a 5-point Likert scale to measure perceptions of

communication, were administered to nurses and physicians caring for patients in the PICU,

before implementation of the goal sheet (N = 419) and after implementation (N = 387). Overall

response rates for the pre- and post-intervention questionnaires were acceptable (68% and 65%,

respectively).

This study demonstrated a perceived improvement in communication of patient goals

after implementation of the goals sheet. Nurses’ understanding of the goals of care increased

from a mean of 4.2 ± 0.8 (n = 229) to 4.5 ± 0.6 (n = 174), p < .001(Agarwal et al., 2008).

Residents’ understanding of the goals increased from a mean of 4.0 ± 0.6 (n = 187) to 4.7 ± 0.5

(n = 213), p < .001 (Agarwal et al., 2008). Furthermore, the nurse’s ability to identify the

attending physician and fellow increased (75% ± 0.4% to 92% ± 0.3%, p < .001, and 79% ±

0.4% to 93% ± 0.3%, p < .001) (Agarwal et al., 2008). The authors reported that LOS did not

decrease significantly (mean days 4.1 to 3.7, p > .05) after implementation of the goals sheet and

discussed possible reasons for this finding regarding LOS. They concluded that due to the lack of

data concerning acuity of PICU patients pre and post intervention, it is possible that acuity may

have been a confounding factor.

Strengths of this study are the inclusion of nurses’ and physicians’ perceptions as well as

the additional outcome measure of LOS. Survival analysis was performed using the log-rank test

and Kaplan-Meier, which are suitable for measuring LOS. Limitations are the lack of

generalizability due to the single setting, the lack of psychometric data for the questionnaire, lack

of assurance that the goal sheet was used in all cases post implementation, and no control group.

The limitation imposed by the lack of a control group is the inability to attribute the improved

communication or LOS to the intervention alone. The authors mention all of these limitations,

??

except for the lack of evidence for validity and reliability of the questionnaire. However, the

combined results of the three studies investigating the use of daily goal sheets offer a growing

body of evidence to support the hypothesis that a daily goal sheet improves communication and

potentially decreases LOS.

Two other studies investigated the impact of specialized forms on communication and

information exchange. Heffner et al. (1998) examined the influence of a computer-based system

with a specialized order form on the communication of do-not-resuscitate (DNR) orders for

critically ill patients. Data were collected for three distinct periods. Period 1 consisted of usual

care (orders for DNR written in the standard doctors’ order sheets); in period 2, a procedure-

specific DNR order form was used; and in period 3, both the procedure-specific form as well as a

computer-generated communication sheet was used. In addition, residents and nurses received an

educational in-service at the start of period 3 and monthly thereafter. A nurse trained in

nondirective interviewing collected the results. Findings demonstrated improved communication

of DNR status for analyzed patients (n = 147) after implementing the computer-based system and

the procedure specific order form. Questionnaires were analyzed for a composite measure of

agreement between physicians and residents and physicians and nurses. Overall agreement

between physicians and nurses improved from period 1 (n = 40, 22.2%) to period 3 (n = 71,

61.9%, p < . 001). The authors noted that although there was increased agreement or

concordance, ideally complete agreement of DNR status is desirable (Heffner et al., 1998).

A strength of Heffner and colleagues’ (1998) study was the comparison to a control

period before use of the computer-based system within the same setting. Limitations included the

single setting, which restricts generalizability, and use of a tool without discussion of validity

and reliability. Also, the rationale for the three different periods, each with an additional

?@

modification to the DNR order process, was not provided. This added ambiguity to the

intervention. Furthermore, the increase in agreement could be due to the increased focus on the

issue of DNR status itself.

Lastly, Pageler et al. (2014) investigated the use of an electronic medical record-

enhanced checklist and a multi-patient electronic dashboard designed to display an overview of

compliance with practices to decrease CLABSI. A secondary outcome measure in this study was

the effect of the checklist and dashboard on communication between nurses and physicians.

Information regarding the impact on communication was solicited through one survey question

that asked, “How effective is the current rounding format in the PICU for communicating your

patient’s needs to all team members?” (Pageler et al., 2014, p. e742). However, this question

does not directly address how the checklist and dashboard in the EHR impacted communication;

rather, it generally ascertains if the “rounding format” improves communication. This

demonstrates the authors’ presumption of a relationship between documentation tools, such as

the checklist in the EHR and its use for communication; however, the study design did not

measure this concept adequately. Preliminary data collected by Thate, Couture, and Collins

(2016) explored how information is shared through documentation regarding CVC management

and the prevention of CLABSI. This work revealed that the use of a checklist during

interprofessional rounds did not necessarily facilitate improved information sharing as perceived

by nurses. Further research of how checklists or dashboards impact team communication is

needed.

These studies (Agarwal et al., 2008; Heffner et al., 1998; Pageler et al., 2014; Phipps &

Thomas, 2007; Pronovost et al., 2003) describe the use of a specialized form to increase

communication and warrant consideration when seeking to understand how information is


?A

exchanged between the nurse and the physician. Electronic records may be re-configured to

present information already documented, in formats that facilitate communication. To do so,

forms that have shown potential for improving communication should be taken into account to

ascertain which aspects of these forms are most useful. There is evidence that a specialized form

can be effective in promoting the communication of goals of care (Agarwal et al., 2008; Phipps

& Thomas, 2007; Pronovost et al., 2003). However, two studies that have examined the use of

computer-based formats for information sharing are inconclusive (Heffner et al., 1998; Pageler et

al., 2014).

Synchronous Oral Communication and Related Issues

Research to date on the exchange of information has shown that clinicians prefer face-to-

face communication and do not regularly utilize an information source such as the patient record

when seeking patient information (Brown et al., 2004; Coiera et al., 2002; Collins et al., 2011).

Although face-to-face or oral communication is important, it is influenced by many issues. First,

synchronous communication between nurses and physicians is not always possible or is limited

in many settings (Coiera, 1996; Street & Blackford, 2001; Zwarenstein et al., 2013). When

synchronous communication is possible, it often results in interruption, which can further

contribute to errors and inefficiencies (Alvarez & Coiera, 2006; Coiera & Tombs, 1998; Coiera

et al., 2002; Edwards et al., 2009). Other issues with face-to-face communication include the

influence of hierarchy or power differentials between the nurse and physician (Leonard et al.,

2004; Liu et al., 2014) and the underrepresented view of the nurse during oral exchanges

(Rowlands & Callen, 2013; Weber et al., 2007; Zwarenstein et al., 2013).

?B

Interruption Related to Synchronous Communication

Early work by Coiera (1996) and Coiera and Tombs (1998) sought to uncover how

information and communication interrelate in the healthcare arena. In Coiera’s (1996) study,

interviews were conducted with medical, nursing, and clerical staff (n = 23) to guide the

observations of 12 participants (physicians n = 8, nurses n = 2, radiographers n = 2).

Ethnographic techniques were used to formulate models of the observed communication

patterns. Findings indicated that there was a bias for synchronous communication despite its

interruptive nature. Several explanations for the preference for synchronous channels were

suggested: (1) lack of asynchronous channels at the study hospital; (2) the “event-driven

environment” prompting the need to ensure that communication was received; (3) the complexity

of a particular issue; and (4) the lack of consideration of the interruptive nature of synchronous

communication (Coiera, 1996, p. 18). The authors also identified and described three

fundamental characteristics of communication in the hospital setting: (1) the need for

communication to accommodate the spatial separation of clinicians due to their mobility; (2) the

interruptive nature of communication; and (3) the team-based nature of work, requiring frequent

communication (Coiera 1996). In a second very similar non-participatory, qualitative

observational study, the interruptive nature of synchronous communication was explored (Coiera

& Tombs, 1998). The researchers conducted observations, totaling 29 hours and 40 minutes, of

eight physicians and two nurses in the medical ward of a 500-bed teaching hospital. This study

confirmed findings from the previous study by Coiera (1996) and added that a lack of

information about whom to contact and the preference for oral exchanges over printed materials

resulted in a highly interruptive environment (Coiera & Tombs, 1998).


?C

These two studies highlight circumstances that warrant synchronous communication as

well as a need to facilitate asynchronous exchanges, when appropriate, to lessen the impact of

relying primarily on synchronous means. The bias toward synchronous exchanges and their

interruptive nature is further substantiated by the aforementioned study (Coiera et al., 2002),

which found that a majority of communication and information exchange was accomplished

through face-to-face conversation (82%) and that a significant portion of these were categorized

as interruptions (30.6%). Efforts to identify instances when asynchronous means are effective

has the potential to lessen interruptive communication events.

Building upon Coiera et al.’s (2002) earlier work, Alvarez and Coiera (2006) conducted

observations of ward rounds in the ICU of a large teaching hospital. Unique to this study was the

focus specifically on rounds and the distinction between two types of interruptions—

conversation-initiating interruptions and turn-taking interruptions. The authors defined

conversation-initiating interruptions as “a communication event not initiated by the observed

subject” and turn-taking interruptions as occurring “within an individual communication event,

when one individual begins speaking before the other finishes” (Alvarez & Coiera, 2006, p. 792).

In this study, 492 events were categorized as turn-taking interruptions, and 345 events were

categorized as conversation-initiating interruptions. This indicates a much higher occurrence of

interruptions when turn-taking interruptions are taken into account. Other findings from this

study further demonstrate the significant time spent in communication (75% of time, 95% CI

[72.6, 77.0]) and the primary use of synchronous channels (88% of communication events).

Edwards et al. (2009) conducted a qualitative time-and-motion observational study to

explore communication patterns between nurses and physicians and the use of information

communication technologies. The observations were conducted in two settings—a tertiary care

?D

hospital and a smaller not-for-profit acute care hospital. Of the clinicians observed, 18 worked in

the ED (six physicians, 12 nurses), and one physician worked in internal medicine. Through

observation, the researchers recorded time spent in inter-clinician communication, noting also

the nature of the communication event, which included the use of both synchronous and

asynchronous channels. This study confirmed the bias for synchronous communication channels

(84.9 % of all communication events for physicians, and 80.6 % for nurses) and the highly

interruptive nature of synchronous communication, noting that all interruptions were due to the

use of synchronous communication (Edwards et al., 2009). Asynchronous channels included the

computerized patient record, paper forms or charts, written paper notes, personal pagers,

overhead pagers, and personal digital assistants. Of these asynchronous channels, the

computerized record was used most frequently (11.5% of communication events for physicians,

and 5.3% for nurses) (Edwards et al., 2009).

Both nurses and physicians “received more interruptions than they initiated,” and the

authors noted that this makes these two groups particularly suited for efforts to enhance

asynchronous communication to reduce the number of interruptions (Edwards et al., 2009, p.

634). The authors pointed out that asynchronous communication should not aim to replace

synchronous means because synchronous communication plays an important role in

communicating nuance. However, asynchronous channels should be leveraged to reduce

interruptions when possible because several studies have shown that interruptions are ubiquitous

(Alvarez & Coiera, 2006; Coiera & Tombs, 1998; Coiera et al., 2002; Edwards et al., 2009).

These studies have also further corroborated preference or bias for synchronous channels.

?E

Power Differentials and the Underrepresented View of the Nurse

Rowlands and Callen (2013) utilized a qualitative design with a grounded theory

approach to explore how information is exchanged between members of a multidisciplinary team

caring for patients with lung cancer in a public teaching hospital. One member of the research

team conducted in-depth interviews with 22 participants and then analyzed the results using an

inductive constant comparative method. Four additional research assistants participated in the

analysis and discussion of themes. Member checking was performed to support the credibility of

the findings. Of note, the patient record in the study site consisted of paper documentation, not

an EHR.

Analysis of the data revealed two main themes: interprofessional communication among

team members and the channels of communication (Rowlands & Callen, 2013). A subcategory

of the first theme, characteristics of interprofessional communication, was the “doctors’

dominance in communications” that was particularly evident during interprofessional team

meetings (Rowlands & Callen, 2013, p. 22). This has implications for the extent to which

nursing knowledge is used to inform care decisions, because weekly team meetings were the

primary medium for planning patient care (Rowlands & Callen, 2013).

Subcategories under the second theme, channels of communication, corroborate prior

research regarding the preference for face-to-face communication. Other themes included the

ineffectiveness of interprofessional team meetings for communication and the inadequacy of

documentation in the record as a means of communication, topics which will be further

discussed in the next section regarding factors that inhibit the use of documentation (Rowlands &

Callen, 2013). In regards to the ineffectiveness of team meetings, the researchers describe these

meetings as “primarily a decision making forum for doctors” noting that although nurses and

@<

allied health were present, input from these groups was minimal (Rowlands & Callen, 2013, p.

26).

To examine issues related to communication and collaboration both interprofessionally

and intraprofessionally, Zwarenstein et al. (2013) conducted a qualitative study of nurses (n = 6,

n = 12), physicians (n = 5 to 9), and allied health professionals (the number of allied health

professions during the observations varied) in two general internal medicine wards. These

researchers used both interviews and observations in an effort to capture a rich description of

interactions. Results indicated that interprofessional exchanges took place primarily in planned

rounds, and physicians’ dominance was evident during discussions with limited input from

nursing or allied health professionals (Zwarenstein et al., 2013). These findings are congruent

with Rowlands and Callen’s (2013) findings. Zwarenstein and colleagues also found that

unplanned interprofessional conversation was rare, once again demonstrating that scheduled

rounds or team meetings are the primary medium for interprofessional communication. These

findings raise questions regarding the current state of interprofessional communication, and

while efforts aimed at improving synchronous exchanges remain important, also critical are

strategies aimed at leveraging the use of documentation for interprofessional communication.

Findings from these two studies converge with those in another (Weber et al., 2007) that

analyzed communication during rounds in an internal medicine setting. The aim of the study was

to “describe the content and mode of patient-physician-nurse interactions” by coding utterances

according to the type and the direction of the exchange (Weber et al., 2007, p. 333). Key findings

from this study indicated that nurses (1449 utterances, 13.5%) contributed considerably less than

physicians (5531, 51.6%) and patients (3733, 34.8%) during ward rounds. The authors concluded

@=

that the lack of input from nurses represents the diminished incorporation of nursing knowledge

during the primary mode of information exchange.

All three of the studies presented in this section supported the importance of regularly

scheduled rounds or team meetings for interprofessional communication, yet they all also

observed the underrepresented view of the nurse during these exchanges (Rowlands & Callen,

2013; Weber et al., 2007; Zwarenstein et al., 2013). These findings are consistent with those in

Conn et al.’s (2009) research, which is presented in the next section. As previously stated,

synchronous interprofessional communication remains an important area of research. However,

equally important is research aimed at improving asynchronous exchanges that overcome some

of the issues related to synchronous channels to facilitate effective interprofessional

communication. Improvements in interprofessional communication depend on the effective use

of both synchronous and asynchronous exchanges. The next section presents the literature on

factors that promote or inhibit the use of documentation for communication.

Factors that Promote or Inhibit the Use of the EHR for Communication

A small body of research has focused on the impact of computerized documentation on

information flow and related processes. All but one of the studies reviewed utilized qualitative

designs. Qualitative themes related to factors that promote or inhibit the use of documentation

for communication are presented; following this, findings from the quantitative correlational

study are discussed.

Conn et al. (2009) explored channels of interprofessional communication to guide future

work on efforts to improve interprofessional collaboration in the general internal medicine

setting. Their aim was to identify factors that promote or impede interprofessional

communication. These authors used communication genre theory to categorize and explore both

@>

synchronous and asynchronous communication. Data were collected through ethnographic

observations and interviews. This design is congruent with the aims that reflect an effort to

“understand the cultural rules underlying a particular custom or practice” (i.e., communication)

(Brink, 1998, p. 311). Results centered on themes around synchronous and asynchronous

communication genres. Within the synchronous communication genre, two themes were

identified: “advantageous opportunistic encounters” and “challenges with oral-only exchanges”

(Conn et al., 2009, p. 947). These themes highlighted the importance of being able to verify

messages between professions through synchronous (face-to-face) communication, while also

identifying the need to reinforce information through documentation in the patient record. The

need to verify messages orally to confirm receipt of a message is congruent with Coiera’s (1996)

research. Conn et al. also noted the ability of healthcare staff and professionals to communicate

through unplanned or opportunistic encounters despite lack of familiarity with the individual

with whom they were talking. This reflects the concept of “common ground” in Coiera’s

framework, which suggests that when individuals lack common ground, synchronous

communication is preferred (Coiera, 2000).

There were several issues subsumed within the theme “challenges with oral-only

exchanges.” First, participants reported a potential threat to patient safety when relying purely on

recall of information from oral discussions. They also noted the need for documentation to

reflect conversations so that information could be conveyed to other members of the healthcare

team. Collins et al. (2011) also described this concept of “information loss” due to a reliance on

synchronous channels. Conn et al. reported that interprofessional rounds were the primary

medium for exchanging information but noted from observations and interviews that there was

an absence of direct-care nurses from rounds due to the timing of the meetings, which left only

@?

the charge nurse to relay patient information. This further supports the finding that the nurse's

view is underrepresented.

Collins et al. (2011) conducted ethnographic observations of morning rounds, a focus

group, and interviews to explore the communication of common goals in a neurovascular ICU.

Clinicians included in the observations were nurses, respiratory therapists, residents, and

attending physicians. Though this study focused on the communication of goals, broader

implications related to the use of the EHR were discussed. The use of two theoretical

frameworks—Coiera’s clinical communication space and distributed cognition— to guide the

methods and analysis was a strength of this study. Coiera’s framework posits how common

ground between clinicians impacts the use of synchronous versus asynchronous channels

(Coiera, 2000). The theory of distributed cognition purports that cognition is not purely

individual but is distributed across elements of the activity system, including individuals, the

environment, the supporting artifacts or tools, and the group's goal-oriented actions (Hazlehurst

et al., 2008).

Observations of morning rounds revealed that two artifacts were used to support the

discussion—the EHR and personal paper notes (Collins et al., 2011). Through observations and

clinician’s reports, researchers found that the EHR was used minimally for exchanging

information; in most cases, such information was sought orally. An exception to this was when

clinicians were seeking information regarding vital signs or intake and output, which can be

found on graphical flow sheets (Collins et al., 2011). Factors that inhibited the use of the EHR

when seeking information included: (1) the lack of information regarding the goals or intent for

documented information such as the rationale for a particular order; (2) the concern that the

@@

documentation in the record was “ a shift behind”; and (3) difficulty finding information in the

record (Collins et al., 2011, p. 197).

Gilardi and colleagues (2014) examined how information is exchanged among the

healthcare team in the ED and the impact of interprofessional relationships on “computer-

assisted information flow” (p. 1301). The researchers conducted a qualitative exploratory study

utilizing direct observations and semi-structured interviews (n = 26) with treatment room nurses,

triagists (also nurses), and physicians. The aim was to identify “patterns of information

exchange” and the “distribution of tasks” (Gilardi et al., 2014, p. 1301). According to the

authors, the theory of distributed cognition was used to guide data collection. The researchers

focused specifically on the interpersonal dynamics and roles within the activity system, which

included the triage nurse, the nurse’s work desk, and a physician and a nurse pair.

Findings revealed three themes describing nurses’ roles related to the flow of information

in the ED when working with physicians: “information highlighters,” “memory keepers,” and

“process organizers” (Gilardi et al., 2014, p. 1299). These roles reflected the ways in which

nurses coordinated the flow of information, which were used to offset deficiencies in strictly

computer-based exchanges. In some cases, these actions might be considered workarounds,

whereby the presence of information in a computer record did not convey sufficiently the

subtleties of a situation or highlight key pieces of information perceived necessary to make a

clinical decision. The use of workarounds provides insight into factors that inhibit the reliance on

an asynchronous channel for the exchange of information. Another key finding was that the

nurses' effectiveness in these roles was dependent on the quality of their relationship with the

physician with whom they were working and the impact of “the authority gradient between

doctors and nurses” (Gilardi et al., 2014, p. 1305).


@A

In the aforementioned study by Rowlands and Callen (2013) on how information in the

paper record is exchanged among members of a multidisciplinary lung cancer team, participants

described specific issues related to the inadequacy of documentation in the record. It is important

to reiterate that a paper record was used in this study. Identified issues were the incompleteness

of documentation, the perception that notes were not read, and the lack of information from

conversations transferred to the record (Rowlands & Callen, 2013). Participants suggested two

key strategies for improving the effectiveness of the patient record in supporting communication.

One suggestion was to move to an electronic record to improve access, an identified advantage

of an EHR (Embi et al., 2013; Kossman & Scheidenhelm, 2008). The second suggestion was to

develop policies to guide documentation practices. These suggestions support a need for shared

consensus regarding what, when, and where information should be documented so that the EHR

can support the intended purposes, which is the aim of the proposed Delphi study.

Embi et al. (2013) conducted a qualitative study of computerized provider documentation

(CPD) to explore the issues and advantages of this technology as it relates to information needs.

CPD is defined as a subset of the EHR that includes documentation regarding the patient’s

history, progress, and plan of care (Embi et al., 2013), which is similar to how the EHR has been

defined for this paper. Fourteen focus groups were conducted with nurses (RNs n = 34, LPNs n =

4), practitioners (MDs n = 45, NPs/PAs n = 9), and administrators (n = 37) at geographically

diverse Department of Veterans Affairs Health Administration (VA) sites. Focus groups were

conducted separately with each of the three groups. The description of the sample and setting

contains sufficient detail and aids in determining the transferability of the findings. The authors

defined practitioners as “inpatient and outpatient primary care and subspecialty providers,” but

@B

they do not distinguish among physicians, physician assistants, and advanced practices nurses

(Embi et al., 2013, p. 719).

The following themes were identified: “communication and coordination,” “control and

limitations of expressivity,” “information availability and reasoning support,” “workflow

alteration and disruption,” and “trust and confidence concerns” (Embi et al., 2013, p. 720, 723).

Of note, the themes were consistent among participants from like groups, but differences

between the three groups (nurses, practitioners, administrators) were identified. One key

difference between nurses and practitioners (MDs/ NPs/PAs) was that nurses placed importance

on “communication and coordination,” whereas practitioners placed importance on “finding

information to support decisions,” which in turn is associated with creation versus consumption

of documentation (Embi et al., 2013, p. 724). In other words, nurses’ focus was on creating

documentation to facilitate communication, whereas practitioners’ focus was on using the CPD

as an information source.

Participants identified several limitations of the computerized documentation system

included within the five aforementioned themes. Within the theme of communication and care

coordination, participants described the lessening of face-to-face discussions because it was no

longer necessary to go to a certain location to access the record, the challenge of piecing together

information from disparate aspects of the record to understand the "big picture," the use of

workarounds within the computerized system to confirm receipt of messages or to have

discussions, and a lack of explicit documentation for care goals (Embi et al., 2013). Within the

theme of control and limitations of expressivity, participants described the restrictions placed on

documentation through template formats resulting in redundant and less useful documented

information with loss of context (Embi et al., 2013). Within the theme of information availability

@C

and reasoning support, participants described overall challenges with finding information in the

system, which caused practitioners to resort to reading very few notes, focusing primarily on

their own notes (Embi et al., 2013). Within the theme of workflow alteration and disruption,

participants raised concerns (a) that documentation was not up-to-date because notes reflecting

decisions in morning rounds were not entered until later in the day and (b) that the system forced

duplicate documentation of information (Embi et al., 2013). Within the theme of trust and

confidence concerns, participants “affirmed that the primary purpose of documentation was to

convey clinical thinking, share information, and coordinate the care team” (Embi et al., 2013, p.

723), yet they also described a lack of quality in documentation due to copy and paste features

and templates.

Despite the identified limitations of CPD, participants noted some advantages: (a) the

documentation system served as a primary source for information regarding patients and (b)

improved access to health information due to the use of a computerized record (Embi et al.,

2013). Also noteworthy is the participants’ assertion that “the primary purpose of documentation

was to convey clinical thinking, share information, and coordinate the care team…” and their

belief that some elements of the computerized system supported this purpose (Embi et al., 2013,

p. 723). Participants recognized clinical summaries as a potentially useful tool and expressed a

need for “best practices” to guide the effective use of computerized systems (Embi et al., 2013).

The utility of clinical summaries, expressed by the study participants, is congruent with findings

from Rowlands and Callen (2013) and suggests a need for direction on how computerized

documentation should be used. Delphi methodology is well suited to address this need.

Kossman and Scheidenhelm (2008) utilized a qualitative descriptive approach to explore

nurses’ use and perceptions about the EHR in relation to their work and patient outcomes.

@D

Surveys, interviews, and observations were used to collect data, thus enhancing credibility and

trustworthiness. The researchers obtained a convenience sample of nurses from both a medical-

surgical floor and an ICU in two community hospitals. The inclusion of nurses from both a

medical-surgical unit as well as an ICU is a strength of this study. Qualitative data analysis

revealed that nurses perceived that the EHR both enhanced and hindered their work because

while they believed EHRs increased access to patient information, they also felt that their notes

were not read by their fellow nurses or physicians, thus hindering interprofessional

communication (Kossman & Scheidenhelm, 2008). Rationales suggested by participants for why

physicians did not read notes included problems locating notes in the chart due to inconsistent

charting locations and physicians’ lack of familiarity with the EHR (Kossman & Scheidenhelm,

2008). It is remarkable that despite of the barriers to interprofessional communication, nurses

also thought that the EHR improved patient safety.

Street and Blackford (2001) conducted a qualitative study with a critical approach. This

approach is used to challenge existing norms and to stimulate change (Cohen & Crabtree, 2006).

Consistent with this approach, these investigators used focus groups and semi-structured

interviews, along with follow-up phone calls and seminars to verify findings. The aim of the

study was to investigate interprofessional communication and to develop suggestions regarding

ways to improve communication. A purposive sample of nurses working in three settings

(community, hospice, and acute care) was recruited. Using qualitative content analysis, the two

researchers independently coded transcribed text. The identification of communication channels

versus strategies to address issues with communication was not clearly described. Some of the

themes identified include the “transmission of relevant practice knowledge” and “lack of

standardized documentation” (Street & Blackford, 2001, pp. 646 & 648). The first emphasizes

@E

the need for clinicians from different professions to be aware of what types of information are

needed for others to carry out their professional role. The second is closely related, and it

describes issues related to the lack of commonality in documentation, resulting in redundancy in

documentation in order to satisfy the format preferences for each group of clinicians. Another

issue noted was the inadequate inclusion of information exchanged orally in the documentation.

Furthermore, Street and Blackford suggested that accurate and complete documentation is

essential to support communication when clinicians have limited opportunity for synchronous

exchanges due to working in different time blocks or physical locations.

Keenan and colleagues' (2013) aim was to explore information management and the

nursing practices related to information flow in a large teaching hospital and two community

hospitals. The authors used the ethnographic observation method, which included the

examination of artifacts used in communication and data from participant interviews. The sample

was obtained using a convenience method; however, efforts to achieve as much variation as

possible in the sample were described. This resulted in a sample that included varied hospital

types, units with diverse adult patient populations, and nurses with different experience levels.

The researchers identified three themes from the data: “variation in documentation and

communication practices,” “the absence of a centralized care overview” as a means for sharing

the most vital patient information between health professions, and “the rarity of interdisciplinary

communication” (Keenan et al., 2013, pp. 247-249). These themes were considered barriers or

challenges to nurses’ information work, which the authors described as retrieving, documenting,

and communicating patient care information. The first two themes focused on the persistence of

paper documents, in spite of the EHR, to support information work. One commonality among all

settings was the use of a paper document to provide an “overview of patient status and care

A<

needs” (Keenan et al., 2013, p. 249). In their discussion of the findings, the researchers built a

case for the need to design electronic tools that take into consideration these practices. Also

common to all settings was the limited interprofessional communication. Although not stated

explicitly, the researchers seemed to be referring only to synchronous communication when

describing the lack of interprofessional exchanges. The researchers also described the observed

challenges with synchronous exchanges either in person or by phone due to being located on

different units as well as the issue of information loss due to the infrequent documentation of

information from these oral exchanges.

Varpio et al. (2009) explored how the use of “workarounds” employed when using an

EHR affected interprofessional communication. Their findings revealed differences in how

novice versus expert physicians managed the implications of workarounds; expert physicians

were more likely to engage in follow-up communication to ensure that the message was

conveyed clearly. This study was carried out in a pediatric in-patient unit, and purposive

sampling was used to recruit nurses (n = 62) and doctors (n = 14) for observations and

interviews. One of the key findings was that more experienced physicians are aware of the need

to orally clarify intent with nurses when they have used “workarounds” in the EHR that they

believe will produce potentially confusing information. What was not considered in the

discussion that followed was that the details conveyed orally to provide clarification were subject

to information loss.

The final two studies (Graetz et al., 2014; Lanham, Leykum, & McDaniel, 2012)

explored how the characteristics of a team of clinicians influenced the use of the EHR. Although

conducted in ambulatory care and primary care settings, these studies identified factors, such as

common ground or team cohesion, that should be considered when exploring the use of the EHR

A=

for communication in the acute care setting. Lanham et al. (2012) conducted qualitative research

to explore the relationship between within-practice communication patterns and EHR use in an

ambulatory care setting. In this study, within-practice communication refers to communication

among members working in the same practice. The theory of complex adaptive systems and a

previously developed model of practice relationships guided the study. A combination of semi-

structured interviews and direct observation was used. The researchers reported spending

approximately 720 hours in the field.

Analysis of field notes and audio transcriptions of interviews resulted in the identification

of themes that were further categorized into three areas, “within-practice communication

patterns,” “practice level EHR use,” and “communication patterns and standardized EHR use”

(Lanham et al., 2012, pp. 386 & 387). The first two categories were also analyzed for

associations. The authors found that practice-level EHR use was higher in practices in which

within-practice communication was strong. In other words, those with established effective

communication practices prior to EHR use were described as having “high” EHR use, which

included its use for communication among nurse-physician dyads. Because the unit of analysis

was nurse-physician pairs and not communication between the individual nurse and physician,

the investigators were not able to analyze how nurse-physician relationships influenced

communication (Lanham et al., 2012).

Lastly, Graetz et al. (2014) surveyed primary care clinicians in 2005 (N = 565), 2006 (N

= 678), and 2008 (N = 626) throughout the implementation of an integrated EHR system.

Respondent characteristics were compared for each year. The survey was designed to measure

care coordination and team cohesion after implementation of an integrated EHR. The sample

consisted of primary care clinicians, including physicians, nurse practitioners (NP), and

A>

physician assistants (PA), working in a large prepaid integrated delivery system in northern

California (Graetz et al., 2014). All primary care clinicians working in the system were

considered the target population and were contacted to participate. The response rates for the

three years, 2005, 2006, 2008, were 48%, 62%, and 61% respectively. These response rates were

adequate for mailed surveys (>50%), except for the first year.

The objective of the correlational study was to examine whether there was an association

between team cohesion and the use of an integrated EHR and care coordination, the latter of

which was measured by an investigator-developed survey using a five-point Likert scale. The

authors implied face validity by referencing a report on care coordination that supported the

concepts included in their survey but otherwise provided no psychometrics for their tool. Team

cohesion was measured using a previously published validated instrument (Ohman-Strickland et

al., 2007). In teams with higher cohesion, there was a significant positive association between

use of the EHR and perceived access to information (p < .05) as well as with clinician’s

perceived agreement on the patient’s treatment goals (p < .05) (Graetz et al., 2014).

Limitations identified by the authors include lack of generalizability due to the specific

setting and EHR system, self-report of team cohesion and care coordination, and the potential

effect or bias from evaluating both variables at the same time (Graetz et al., 2014). Because

measures were based on self-report, clinician agreement on the treatment plan was entirely

subjective and subject to recall bias. However, insight may be gleaned from this study regarding

the potential impact of team characteristics on information exchange and communication. This

should be considered when examining physicians' use of nursing documentation.

In summary, this chapter examined studies to ascertain what factors promote or inhibit

EHR use for communication. From these studies, the availability of the EHR, as compared to

A?

previously used paper records, was the only factor identified that promotes the use of

documentation for communication and care coordination (Embi et al., 2013; Kossman &

Scheidenhelm, 2008; Rowlands & Callen, 2013). Several studies also found that team cohesion

or the relationship between clinicians promotes the use of the EHR for communication and

coordination (Gilardi et al., 2014; Graetz et al., 2014; Lanham et al., 2012). In contrast, many

common themes centered on factors that inhibit the use of the EHR for communication have

been identified, as summarized below.

1) The need to orally clarify or confirm the receipt of messages (Embi et al., 2013; Gilardi et

al., 2014; Varpio et al., 2009). Coiera (1996) suggested that clinicians’ bias towards

synchronous exchanges was due to this need to verify that a message was received.

2) The issue of information loss due to the infrequent documentation of information from

conversations in the EHR (Collins et al., 2011; Keenan et al., 2013; Rowlands & Callen,

2013). The perception that the EHR lacks critical information from oral exchanges

perpetuates reliance on face-to-face exchanges.

3) Perceptions that the EHR is not up to date because summary notes commonly are written

at a later time (Collins et al., 2011; Embi et al., 2013).

4) Reported and perceived difficulty finding information in the electronic record (Collins et

al., 2011; Embi et al., 2013; Kossman & Scheidenhelm, 2008).

5) Documentation does not include goals of care (Collins et al., 2011; Embi et al., 2013).

6) Concern regarding the low quality of documentation in part due to constraints in

computerized systems (Embi et al., 2013; Rowlands & Callen, 2013; Street & Blackford,

2001).

A@

7) The perception that notes are not read by fellow clinicians (Kossman & Scheidenhelm,

2008; Rowlands & Callen, 2013).

8) The lack of a patient overview or summary to synthesize patient information (Embi et al.,

2013; Keenan et al., 2013).

Thus far, three areas of literature related to the use of documentation for interprofessional

communication have been presented. Most of the quantitative studies presented were descriptive

and demonstrated the frequency of use of documentation, but they did not provide insight into

why documentation is minimally used. The qualitative studies provided a much richer picture of

the issues surrounding the use of documentation to support interprofessional communication.

The “thick” descriptions and the use of triangulation in several of the qualitative studies, in

which both observations and interviews or focus groups were used, were methodological

strengths. Findings suggest that when documented patient information is sought, the primary

purpose is to understand the patient’s status and to make clinical decisions; however, there is no

clear indication as to what type of documented information or format supports these purposes

from the perspective of both the nurse and the physician. The qualitative literature also provides

insight into factors that promote or inhibit the use of the EHR for interprofessional

communication. What is lacking is mutually agreed upon “best practices” or policies that can be

used to guide and formally evaluate the effective use of the EHR for interprofessional

communication. The proposed Delphi study provides a methodological approach suited to

address this gap by seeking expert input regarding best practices.

Healthcare-associated Harm and CLABSI

There are many issues related to quality and safety that would benefit from greater

understanding around how to leverage the EHR to support interprofessional communication. To


AA

explore this concept, the prevention of CLABSI was selected to provide a context for the

examination of what information should be communicated asynchronously versus synchronously

and what factors promote or inhibit the use of the EHR for communication.

Healthcare associated infections (HAI) contribute to significant morbidity and mortality

(CDC, 2011; Klevens et al., 2007; Ziegler, Pellegrini, & Safdar, 2014). In addition, HAIs have

implications for increased healthcare costs attributable to increased length of stay, subsequent

treatment aimed at eliminating the infection, and nonreimbursable costs (Perencevich et al.,

2007; Stevens et al., 2014). Bloodstream infections, including CLABSI, are responsible for an

estimated 30,665 deaths per year in the United States (Klevens et al., 2007), and according to the

CDC (2011), CLABSI has a mortality rate of 12% to 25%. Additionally, CLABSIs account for

an increase in cost of approximately $32,000 per patient (Stevens et al., 2014).

The fact that these infections are by and large preventable warrants continued efforts

aimed at reducing CLABSI. Graded evidence for best practices regarding prevention strategies

for HAIs has been outlined (O’Grady et al., 2011; Yokoe et al., 2014). Particular to CLABSI, the

guidelines include interventions aimed at addressing issues before insertion, during insertion,

and after insertion. A risk factor related to post-insertion is prolonged duration of catheterization

(Latif, Halim, & Pronovost, 2015). Therefore, the removal of nonessential catheters has been

identified as one of the post-insertion strategies for the reduction of CLABSI (O’Grady et al.,

2011; Yokoe et al., 2014). Efforts thus far to address CLABSI have focused primarily on

insertion checklists and insertion kits, which target pre-insertion or at-insertion issues. Although

these initiatives include prompts for daily discussion regarding the continued need for the CVC,

to this author’s knowledge, no studies have explored the communication dependencies aimed at

decreasing dwell time and eliminating CVCs that are no longer necessary.

AB

The risk of developing a CLABSI during day 1 to 5 is 2.1 per 1000 catheter days,

whereas the risk for lines in place for day 16 to 30 is 10.2 per 1000 catheter days (McLaws &

Berry, 2015). Another study found that instances of CLABSI were associated with catheters that

had been in place for a mean of 17 catheter days (McNamara, Adams, & Dellit, 2011). This is

consistent with McLaws and Berry’s study that reported an increase in risk for infection on day

16 to 30. Burdeu, Currey, and Pilcher (2014) observed that after discharge from the ICU, 26.2%

of catheter days were deemed idle (meaning in place without a medical indication). This problem

is further compounded when providers are not aware of the presence of the catheter.

In Chopra and colleague’s (2014) study, 21.2% of providers were unaware of the

presence of a CVC in patients in their care. In their study, providers were defined as an intern,

resident, nurse practitioner, physician assistant, or attending physician. Only providers’

awareness was assessed; nurses’ awareness was not measured. Facilitating the sharing of nurses’

knowledge through the patient record regarding CVCs has the potential to increase provider

awareness. Tracking the necessity of the CVC has been recognized as an important strategy to

eliminate nonessential lines and reduce the risk of CLABSI (LeMaster, Hoffart, Chafe, Benzer,

& Schuur, 2014; McNamara et al., 2011; Richardson & Tjoelker, 2012; Zingg et al., 2014). This

should include not only awareness of the presence of the line, but also what indications support

continued placement or discontinuation. Efforts to facilitate prompt removal of a CVC are

dependent on clinical judgment and accurate data to support the decision (O’Grady et al., 2011).

Initiatives that have been successful in the reduction of CLABSI have utilized a multi-

modal approach. In a meta-analysis of quality improvement interventions targeting CLABSI,

Blot, Bergs, Vogelaers, Blot, and Vandijck (2014) found that a decrease in infection rates was

more apparent in initiatives utilizing bundles, which typically include the implementation of

AC

three to five evidenced-based strategies in concert. However, Blot et al. also noted that the

findings regarding sustained reduction of CLABSI are not clear, and that it is difficult to

determine whether the Hawthorne effect was partly responsible for reductions in CLABSI,

perhaps due to increased communication and collaboration during the quality improvement

intervention. Weeks, Goeschel, Cosgrove, Romig, and Berenholtz (2011) pointed out that

standardized procedures and checklists are important to the provision of safe care; however, they

are ineffective in the absence of teamwork and collaboration.

One large multi-site study (Pronovost et al., 2006) aimed at preventing CLABSI that was

not included in the meta-analysis by Blot et al. (2014), reported a sustained decrease in infection

rates at 18 months. In this study, ICUs implemented interventions based on the five evidenced-

based strategies recommended by the CDC (Pronovost et al., 2006). Interestingly, Pronovost et

al. also described the simultaneous implementation of a daily goals sheet to improve

communication during this initiative. As a result, it is unclear whether the sustained reduction of

CLABSI can be attributed to the evidence-based strategies or to improved communication.

Extending this idea in a secondary analysis, Boev and Xia (2015) found that nurses’ perception

of poor nurse-physician collaboration was related significantly to increased rates of CLABSI and

ventilator-associated pneumonia (VAP). Nurse-physician collaboration was measured using the

Collaboration and Satisfaction About Care Decisions (CSACD) instrument, which has evidence

of reliability and validity (Boev & Xia, 2015). Boev and Xia report, “for every 0.5 unit increase

in nurse-physician collaboration, the rate of CLABSI decreased by 2.98 (p = .005)” (p. 70).

CLABSI is measured by number of infections per 1000 central catheter days per month (Boev &

Xia, 2015). These findings along with the use of a daily goals sheet in the study by Pronovost et

AD

al. warrant further exploration of the impact of communication and collaboration on CLABSI

prevention.

Communication among the interprofessional team is important in determining the need

for a CVC as well as for ensuring prompt removal. Prompt removal of non-essential lines has

been identified as a strategy (O’Grady et al., 2011), but to this author’s knowledge, no studies

have explored the communication dependencies aimed at decreasing dwell time and eliminating

CVCs that are no longer necessary. Prompts for discussing the necessity of the line during

interprofessional rounds commonly are included in bundles or checklists; however, the critical

information needed to make such decisions is lacking. Determining the necessity of a line is a

clinically complex decision with multiple dependencies based on various information sources

and clinicians. Thate et al. (2016) found that information related to CVCs was found in disparate

areas of the patient record, and that input from the intravenous therapy (IV) nurse was perceived

to be vital. Yet, the IV nurses were not a part of interprofessional rounds, and documentation of

their assessments was in a separate location from the patient record. Furthermore, studies have

described the underrepresented view of the nurse in interprofessional rounds, suggesting that the

nurses’ input may be limited in these discussions (Conn et al., 2009; Rowlands & Callen, 2013;

Weber et al., 2007; Zwarenstein et al., 2013). Shortening CVC dwell time and eliminating the

continuance of non-essential CVCs requires highly functioning interprofessional teams who

effectively communicate information related to assessment data, plans, and evaluations. Thus,

further exploration of what information is used to determine the need for CVC access and/or

removal and how this information is communicated among the interprofessional healthcare team

is essential.

AE

Theoretical Frameworks

The review of literature thus far has demonstrated that understanding what ought to be

communicated through asynchronous versus synchronous channels is dependent on several

factors. Two theoretical frameworks, distributed cognition and Coiera’s communication space,

aid in understanding these factors. These models provide a structure for exploring

communication tasks among the interprofessional team and the supporting role of information

systems.

Distributed cognition, first described by Edwin Hutchins in 1995 in Cognition in the

Wild, has garnered increasing attention in the field of medical informatics (Collins & Vawdrey,

2012; Collins et al., 2011; Galliers, Wilson, & Fone, 2007; Hazlehurst et al., 2008, 2007;

Nemeth, 2006; Patel, Cytryn, Shortliffe, & Safran, 2000; Patel, Zhang, Yoskowitz, Green, &

Sayan, 2008; Tariq, Georgiou, & Westbrook, 2013; Wilson, Galliers, & Fone, 2007). The

primary distinction between distributed cognition theory and traditional cognitive science is the

conceptualization of information processing as a function of the interactions among the human

actors and the technological artifacts in the former, rather than “information processing at the

level of the individual” in the latter (Rogers, 1997, p. 1). The term activity system has been used

to label this broader level of analysis and has been further conceptualized to include the human

actors, the tools or artifacts available, the social environment (including the rules or

understandings that guide actions), and the goal or purpose of the interaction (Hazlehurst, 2015;

Hazlehurst et al., 2008). This shift from analyzing cognition from the perspective of an

individual to the analysis of the activity system as a whole suggests that simply understanding

the information processing of individual actors does not fully consider how elements of the

system interrelate, nor does it consider the context specific influences on information processing

B<

or how cognition “in the wild” occurs (Hazlehurst et al., 2008; Hutchins, 1995; Patel et al., 2008;

Rogers & Ellis, 1994).

According to Rogers and Ellis (1994), the theory of distributed cognition “provides a

framework for analyzing complex, socially distributed work activities of which a diversity of

technological artefacts and other tools are an indispensable part” (p. 121). Some applications of

distributed cognition include the exploration of coordinated communication during open-heart

surgery (Hazlehurst et al., 2007), the role of communication lapses in medication errors (Tariq et

al., 2013), and the communication of common goals in the ICU (Collins et al., 2011). What these

studies have in common is the aim to understand the sharing of information among clinicians to

improve processes that involve information technology to reduce errors. Distributed cognition

supports a system level analysis that avoids a reductionist approach, and this system level

analysis is deemed valuable in the analysis of error in healthcare. Thus, this theory is well suited

to provide a lens through which to explore how the EHR (an artifact) is used to access and share

information among members of the interprofessional team (human actors) in light of the well-

described role of communication in healthcare errors (see Figure 1). Furthermore, this theory

supports the use of the Delphi technique, which aims to reach a shared understanding among

participants through the analysis of group input as a whole, rather than as individual parts, as

well as the explication of what rules or understandings guide their actions.

Coiera (2000) provides another framework for describing how information is exchanged

and the use of information systems. Like distributed cognition, Coiera (2003) argues that

explication of the larger system or “communication space” is necessary for understanding the

complexities of clinical communication. Similar to the activity system, the term “communication

space” is used to describe the interactions and conversations between clinicians, the tools they

B=

use, and their actions as a result of information needs (Coiera, 2000, p. 278; Coiera, 2003). What

this framework adds to the theory of distributed cognition is the conceptualization of “common

ground” and its influence on the use of either synchronous or asynchronous channels for

accessing and sharing information.

Common ground is defined as “the knowledge shared by two communicating agents”

(Coiera, 2000, p 282). Coiera contends that common ground influences the suitability of

accomplishing an exchange of information through a communication task or an information task,

both of which exist on different ends of a continuum within the communication space (see Figure

2). Communication tasks are characterized as informal and synchronous in nature, as illustrated

by an impromptu conversation. In contrast, information tasks are characterized as formal

transactions, accomplished through the use of information technology in an asynchronous

manner. Because building common ground requires a cost on behalf of the participant, a

participant will, based on a cost benefit analysis, take what is perceived to be the least costly

approach when seeking to access or exchange information (Coiera, 2003). In other words, if

communicating through an asynchronous channel such as the EHR is dependent on previous

efforts to develop common ground between clinicians, or between a clinician and the information

system, the clinician will exhibit a bias for synchronous conversations, which require less

grounding ahead of time.

This bias for synchronous channels has been documented empirically (Brown et al.,

2004; Coiera et al., 2002; Collins et al., 2011), as have the factors that inhibit the use of

asynchronous channels (Collins et al., 2011; Embi et al., 2013; Gilardi et al., 2014; Keenan et al.,

2013; Kossman & Scheidenhelm, 2008; Rowlands & Callen, 2013; Street & Blackford, 2001;

Varpio et al., 2009). So why not allow exchanges to follow the path of least resistance? Several

B>

issues inherent to relying solely on synchronous means have been described, including the loss

of information in oral exchanges (Collins et al., 2011; Keenan et al., 2013; Rowlands & Callen,

2013), the interruptive nature of synchronous communication (Alvarez & Coiera, 2006; Coiera &

Tombs, 1998; Coiera et al., 2002; Edwards et al., 2009), and the underrepresented view of the

nurse during oral exchanges (Rowlands & Callen, 2013; Weber et al., 2007; Zwarenstein et al.,

2013). These issues likely play a significant role in the association between communication and

healthcare-related harm, and provide an impetus for further examination of what type of

information should be communicated via asynchronous versus synchronous channels, and the

factors that promote or inhibit asynchronous communication between nurses and physicians.

Coiera’s framework informed the plan for the present study in two ways. First, this

framework guided the formulation of the research questions. The questions address the

communication space as a whole, acknowledging that understanding whether an exchange is best

accomplished through a synchronous or asynchronous channel is dependent on the relationship

between the communicating agents and how they perceive the task. Second, the framework

informed the methods selected to conduct this study. The Delphi technique has been chosen

because it aims to illicit expert opinion; as such, it is suitable to explore how communication and

information tasks are perceived by an expert panel and how they should be accomplished. Also,

because the Delphi technique utilizes a group communication approach with the goal of reaching

group understanding (Linstone & Turoff, 2011), it can be used as a means for establishing

common ground and identifying communication scenarios in which lack of consensus exists.

These data can then provide insight into when and how to facilitate the use of information

systems to support communication and when it is better to support synchronous exchanges.


B?

This chapter opened with a review of literature related to the use of documentation for

interprofessional communication. Three areas of literature were presented: the asynchronous use

of documentation, including patterns and purposes of use; synchronous oral communication

between nurses and physicians and the related issues; and factors that promote or inhibit the use

of the EHR for communication. This chapter then highlighted communication dependencies

related to the prevention of CLABSI, and the prevention of CLABSI was put forth as a model

case for the exploration of the role of the EHR in interprofessional communication. Lastly, two

frameworks that have aided in the conceptualization of this study were presented. The next

chapter will describe the methods used to conduct this study.


B@

Chapter Three: Methodology

Chapter three describes the methods for this study. This chapter begins with an overview

of the Delphi methodology, including how this method is congruent with the identified purpose

of the study. Following this overview, subsequent sections address the setting and sample, data

collection and analytical procedures, and strategies to enhance rigor.

Overview of Research Design and Method

This study used the Delphi technique or method to describe what nurses and physicians

believe regarding how the EHR ought to be used to optimize interprofessional communication

concerning central venous catheter (CVC) management and the prevention of central line–

associated blood stream infections (CLABSI). The study design was longitudinal and included

both qualitative and quantitative data in line with the Delphi method. The Delphi technique can

be defined as a method “to achieve agreement among a group of experts on a certain issue where

none previously existed” (Keeney, Hasson, & McKenna, 2011, p. 4). It can be more broadly

defined as a structured group communication process (Linstone & Turoff, 1975/2002). This

method was selected due to its suitability for the identified study purpose and the paucity of

empirical research on the topic. Listone and Turoff (1975/2002) identify several circumstances

that substantiate the application of the Delphi technique to a particular issue. Of these

circumstances, the following apply to this study: (1) the problem is not amenable to precise

measures or analytics; (2) input on a complex issue is needed from a diverse group of individuals

who do not regularly communicate; and (3) the heterogeneity of the panel is critical to the topic

under study, yet it is equally important to minimize the impact of dominant perspectives that

might occur in other methods (such as focus groups) that could bias the results.

BA

The Delphi method is intended to illicit what could or should be, rather than what is (Hsu

& Sandford, 2007). This makes Delphi a unique form of inquiry that is well suited to forecast or

develop guiding principles. It is vital to recognize that results from a Delphi study represent

informed judgments, rather than statistically proven findings. The Delphi technique was first

used in the 1940s by the U.S. Air Force and then further developed by the RAND Corporation in

the 1950s as a way to “apply expert input in a systematic manner” to a complex issue (Linstone

& Turoff, 2011, p. 1712). It has since been widely used in nursing and healthcare research. In a

review of 100 Delphi studies published between 2000 and 2009, Diamond et al. (2014) reported

that 74 of the reviewed Delphi studies were in the healthcare field. Of these, 12 studies were in

the field of nursing and examined such varied topics as research priorities for adult cancer

research; research priorities in a school of nursing; guidance on the integration of Quality and

Safety Education for Nurses (QSEN) competencies into nursing curricula; quality indicator

themes among African Americans, Latinos, and Whites; and labor support actions of intrapartum

nurses (Diamond et al., 2014). Common to all of these studies is the aim of identifying what

should be based on the judgments of an expert panel.

In spite of the Delphi method’s widespread use, there is no set of standardized procedures

for conducting this type of study. One common element is the iterative process of data collection,

whereby participants who constitute the expert panel provide responses, and then the researcher

summarizes the responses (structured feedback) and presents them back to the participants

(Hasson, Keeney, & McKenna, 2000). This process typically is repeated for two to three rounds

(Diamond et al., 2014), although the classic Delphi consisted of four rounds (Keeney et al.,

2011). This technique allows participants to view their own response in light of the group’s

collective response and, if desired, alter their feedback in subsequent rounds (Keeney, Hasson, &

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McKenna, 2006). The classic Delphi begins with an open-ended question to which the panel

provides a written response (Keeney et al., 2011). In the modified Delphi, the first round may

consist of interviews or focus groups or, in some cases, a predetermined list of items to consider

(Hasson et al., 2000; Keeney et al., 2011). This study employed a modified Delphi beginning

with individual interviews.

Philosophical assumptions of the nature of the world and truth impact how the inquiry is

structured in the Delphi method (Linstone & Turoff, 1975/2002). Linstone and Turoff

(1975/2002) suggest that the Delphi methodology, as developed by the RAND Corporation, was

based on the philosophical underpinnings of Locke and existentialism. As a result, “truth is

experiential” and is validated by “agreement between different human observers” (Linstone &

Turoff, 1975/2002, pp. 20–21). Thus the end goal of consensus becomes a focus of most Delphi

studies (Diamond et al., 2014) to demonstrate agreement regarding some truth. Although

consensus typically has been the aim in Delphi studies, this must be carefully considered.

Consensus has not been consistently defined in Delphi studies, and although it has been

identified as a goal, it has not been measured clearly or used explicitly as stopping criteria in

many reported studies (Diamond et al., 2014). In cases where consensus has been defined, it is

commonly described as a measure of agreement and less commonly as a reduction in response

variance (Diamond et al., 2014).

Linstone and Turoff (2011) contend that although the aim in a Delphi study is seeking

agreement, consensus or a convergence of opinions should not be the guiding principle during

the process. Instead, the Delphi rounds should conclude when stability of responses, measured by

the number of participants changing their response from round to round, is observed (Linstone &

Turoff, 2011). Similarly, Rowe and Wright (1999) define consensus as a measure of the

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reduction of variance in the responses. If this definition of consensus is used, then as Listone and

Turoff assert, stability of responses is the end goal. Thus, the end result may be clarity regarding

areas of both agreement and disagreement (Linstone & Turoff, 2011). Thus, a convergence of

responses is not the aim; in fact, the result could be two distinct groups of thought (Linstone &

Turoff, 2011). This was a plausible possibility in this study due to having both nurses and

physicians on the panel. Results may indicate that nurses agree on the relevance of a particular

item, yet physicians do not. However, because the findings are reported back to the panel

throughout the process, recognition of these differences by the group itself is an often under-

recognized advantage of this method (Linstone & Turoff, 2011).

Continuing with this line of reasoning, another possible output of the Delphi method is

the formation of a “common reality” (Scheele, 1975). Scheele defines reality as “a collection of

observable things and occurrences, which is animated by a society of individuals” (1975, p. 41).

Thus, according to Scheele, the Delphi method results in a socially constructed reality based on

the input of the group. Therefore, the group communication process used in the Delphi technique

may actually contribute to the development of common ground as described by Coiera (2000).

This could occur in two ways. First, awareness of areas of disagreement may expand the

participant’s understanding of the “others” perspective, laying the foundation for future

development of common ground. Second, on items in which participants revise their responses

based on the group’s perspective, the development of a “negotiated reality” emerges (Linstone &

Turoff, 2011, p. 1713). This “negotiated reality” could be considered the formation of common

ground.

Lastly, it is important to note the key characteristics and limitations of the Delphi method.

In a review of the effectiveness of the Delphi technique, Rowe and Wright (1999) suggest four

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key characteristics integral to the method: “anonymity, iteration, controlled feedback, and the

statistical aggregation of group response” (p. 354). However, as previously noted, a limitation of

the method is the lack of a standard set of guidelines resulting in variation in how these key

characteristics are addressed in the application of the technique (Diamond et al., 2014; Hasson et

al., 2000; Linstone & Turoff, 2011; Rowe & Wright, 1999).

In theory, anonymity among panel members eliminates potential social pressures to

conform to the ideas of the group and encourages responses that are based on merit in the eyes of

each individual (Rowe & Wright, 1999). Keeney et al. (2011) assert that there are limitations to

maintaining anonymity, such as lack of ownership of opinions or feelings, or isolation as

opposed to group synergy. They also point out that the researcher must know the identity of the

panel members to facilitate the iterative rounds. Being known to the researcher may influence

panelists’ responses. Furthermore, in some modifications of the Delphi method, the first round

consists of a focus group, which would eliminate anonymity among panel members. These issues

must all be considered when applying the Delphi technique.

Iteration is another key characteristic of the Delphi method; however, the number of

rounds and the methods of providing controlled feedback, as well as the statistical aggregation of

responses, vary in published studies. Although there is no clear set of guidelines for these

aspects, it is suggested that criteria for the number of rounds be set by the researcher a priori and

clearly described in the report of the study (Diamond et al., 2014). Keeney and colleagues (2011)

point out that “many published Delphi studies are not explicit in resultant publications about the

statistical tests used to analyze responses or to provide feedback” (p. 92). If the methods of

providing controlled feedback and the statistical methods used for the aggregation of responses

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are stated explicitly, researchers enable the reader to make informed judgments about the

findings, which strengthens the study.

It is also important to clearly describe standards or criteria for determining what

constitutes an expert. Rowe and Wright’s (1999) analysis suggests that panels comprised of

relative experts with varied viewpoints are important to the effectiveness of the Delphi method.

To evaluate any application of the Delphi technique, what defines an expert must be described

clearly (Diamond et al., 2014). Details regarding how the four characteristics integral to the

Delphi technique were incorporated in this study and how each of the potential limitations were

addressed are included in the following sections describing the sample, setting, and data

collection procedures.

Setting and Sample

Selection of Expert Panel

Selection of the expert panel is one of the most critical aspects of a Delphi study,

however as stated, no clear guidelines exist on how to define an expert. According to Bromme,

Rambow, and Nuckles (2001), an expert is determined by the education and experience of the

person and the type of knowledge he or she possess. This is congruent with Hasson et al. (2000),

who assert that experts have knowledge on the topic being investigated. Adler and Ziglio (1996)

suggest that in addition to knowledge and experience, the experts should also demonstrate the

time and willingness to participate in the process and the ability to articulate their point of view.

A non-probability criterion sampling strategy was used to obtain participants for the

expert panel (Hasson et al., 2000). A criterion sample ensures that the participants are selected

based on specific criteria dictated by the research problem. Criteria for panel selection was based

on membership in selected healthcare professions, experience caring for patients with CVCs, and

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knowledge regarding CVC management and the prevention of CLABSI. Due to the

heterogeneity of the desired panel, categories were specified to attain a particular panel

composition. See Appendix A for a detailed description of the panel criteria. Panel members

were recruited to achieve representation from practicing nurses and physicians who care for

patients with CVCs, intravenous therapy nurses, clinicians who are knowledgeable regarding

infection control and prevention, and nurse and physician leaders in the acute care setting.

Diamond et al. (2014) suggested that to ensure quality in a Delphi study, a clear description of

the panel selection criteria is needed with the goal of being able to replicate the formation of a

similar panel.

Practice setting was not a selection criteria; however, the aim was to have participants

who practice in various inpatient settings. Participants were recruited from three hospitals within

Partners Healthcare, a large not-for-profit healthcare-system in the northeast region of the United

States. The first, Brigham and Women’s Hospital, is a large academic medical center with 747

beds. The other two are community teaching hospitals: Newton-Wellesley Hospital with 313

beds and Brigham and Women’s Faulkner Hospital with 150 beds.

Sample size

The literature on the Delphi method reports sample sizes ranging from five to 500

(Keeney et al., 2011). Several aspects of a study should be considered when determining the

target sample size. These include: (1) the complexity of the question; (2) the form of Delphi

being used; for example, if round one will start with an open-ended question as opposed to a

predetermined list of statements, it may be necessary to have a smaller panel; (3) the time and

resources available to the researcher; and (4) the time required of participants (Keeney et al.,

2011). However, many of these considerations address feasibility rather than study quality.

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Rowe and Wright (1999) aimed to appraise the effectiveness of the Delphi technique by

reviewing studies that evaluated the Delphi method. Included in their review were two studies,

Boje and Murnighan (1982) and Brokhoff (1975) (as cited in Rowe & Wright, 1999) that

compared different size panels; in these two studies, there was no evidence to suggest that panel

size made a difference in the outcome. Okoli and Pawlowski (2004) outlined a specific

procedure for selecting experts and suggested a target sample size of 10 to 18 participants. These

authors purport that due to the nature of the Delphi method, statistical power is not the aim;

instead, the aim is to achieve a group dynamic that supports the process and the purpose of the

study. Skulmoski, Hartman, and Krahn (2007) advised that larger panels are needed when the

group is not homogenous. For this study, the aim was to obtain an 18-member panel consisting

of nine nurses and nine physicians, thus approaching 10 members for each of the two

homogeneous groups (nurses and physicians) within the panel. However, it was recognized that

actual panel size may range from 12-18 participants, dependent on the degree of attrition.

Ultimately, the panel consisted of 10 clinicians in total. For details on specific criteria refer to

Appendix A.

Due to the time commitment required from panel members, there was potential for

participant attrition. This is a potential problem to consider when determining the target sample

size as well as how it may impact representation of the specified groups within the panel. As a

result, it would be important to report details regarding any panel members who did not complete

all rounds. Before the start of the study, all participants were made aware that even if they did

not continue, their previously provided data would be included in the results. Keeney et al.

(2011) suggest that conducting personal interviews in the first round aids in engaging panel

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members, thus decreasing attrition. For this study, round one consisted of individual interviews

in the hopes of minimizing attrition.

Recruitment of Sample

Key informants, in conjunction with snowball sampling, were used to recruit panel

members. Polit and Beck (2012) define snowball or network sampling as “the selection of

participants through referrals from earlier participants” (p. 743). An advantage of this type of

sampling is that it aids in finding participants who meet specific criteria (Polit & Beck, 2012).

Key informants could include nurse managers or medical directors at the study sites who would

assist in selecting practicing nurses and physicians who fit the selection criteria. In addition,

networking through a key contact (S.C.) was used to identify potential nurse and physician

leaders. Once potential participants were identified, snowball sampling was also used.

To obtain the expert panel participants, a recruitment period commenced before the start

of round one. Potential participants were emailed a letter (see Appendix B) explaining the study

purpose and the inclusion criteria for panel members. Contact information for the primary

investigator (PI) was included in the letter so that potential participants could ask questions

regarding the process before agreeing to participate. Also included in the letter was a link in

which participants could view the informed consent (see Appendix C) and complete the

demographic survey if they chose to participate. Once the target panel size was obtained, round

one interviews were scheduled.

Protection of Human Subjects

Institutional Review Board approval from Partners Healthcare System and Villanova

University was obtained before beginning the study. All participants were provided with

information regarding study details and the key elements of informed consent before being

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enrolled in the study and conducting the initial interview. Specific instructions and reiteration of

the study details were provided with each subsequent survey (round). It was made clear to

potential panel members that participation in the study was completely voluntary and that they

could opt to discontinue their participation at any time without penalty or consequence. As noted

previously, participants were made aware, before the start of the study, that even if they did not

continue, their previously collected data would still be included in the study results.

Risks associated with participating in this study were presumed to be minimal. However,

it was possible that participants could experience emotional discomfort from recalling difficult

patient situations or potentially sensitive information related to their work environment. The

informed consent included the name and phone number of the PI, Co-Investigator, and Internal

Review Board (IRB) personnel; participants were encouraged to call the PI if they experienced

emotional discomfort, and the PI would offer support if needed. In addition, the informed

consent included the name and phone number of someone in the research office who could be

contacted if participants had any concerns regarding their participation in the study or the study

itself.

Another potential risk was loss of confidentiality, however, multiple safeguards were in

place to minimize this risk. Participants remained anonymous to all other panel members. The

researcher maintained a list of participants, each with a unique ID code, on an encrypted,

password-protected computer. The researcher used this unique code to provide feedback to

participants during each round. Handwritten notes taken during the interviews were stored in the

researcher’s locked office. All transcribed data, audio files, and typed notes were labeled with

the unique code number and stored on the researcher's encrypted, password-protected computer.

Survey data was collected using REDcap®, a secure Web-based application. Within REDcap®,

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users have individual password-protected accounts to limit access to information. Authentication

was used to validate user identities. For this study, only the PI and one approved member of the

research team (S.C.) had access to the information collected using the REDCap® system. Direct

quotes from participants were used in feedback during Delphi rounds and may be used in written

reports of the study. The participant’s identification will not be revealed in any reports or

publications related to this study. There was no identified individual benefit for the participants;

however, the recognition that findings may be used to guide the development of EHRs that

support interprofessional communication regarding CVC management may be a perceived

benefit.

Data Collection and Data Analytic Procedures

As described in the literature, the Delphi method typically consists of two to four rounds

(Diamond et al., 2014; Keeney et al., 2011; Skulmoski et al., 2007). The number of rounds

should be determined by a priori stopping criteria (Diamond et al., 2014). In most cases, this is

defined as the point at which consensus or stability of responses is reached. When planning for

the number of rounds, it is also important to weigh attainment of consensus against diminishing

response rates (Skulmoski et al., 2007) or “the law of diminishing returns” (Keeney et al., 2011,

p. 81). For instance, respondent fatigue may be a reason to terminate further rounds. For this

study, the modified Delphi was used. Congruent with this, the first round included one-to-one

interviews. Based on previously reported studies using Delphi (Diamond et al., 2014), the

researchers anticipated that four rounds would be conducted, and ultimately four rounds were

needed to achieve stability of responses 8see detail regarding analysis and specific stopping

criteria below). Skulmoski et al. (2007) note that although two to three rounds are typical, in

heterogeneous groups, like the one in the proposed study, more than three rounds may be needed.

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In addition to analysis of data from the interviews and surveys in each of the rounds,

demographic data were summarized. Descriptive statistics were used to describe the

demographic and work-related characteristics of the sample. These characteristics included age,

gender, ethnicity, level of education, years practicing, profession, role, work setting and type of

institution, average hours worked per week, number of patients cared for with CVC in the past

month, whether their institution was using a CLABSI bundle or checklist, and number of years’

experience with an EHR.

Round One Data Collection

Round one began with semi-structured individual interviews with each of the panel

members. Interviews were scheduled after participants accessed the REDcap® Web-link

containing the informed consent document and the demographic survey. Conducting interviews,

rather than asking participants to write out responses to open-ended questions, decreases the

burden on participants and affords the opportunity to develop rapport that may result in improved

engagement throughout the process (McKenna, 1994). Interviews were conducted virtually using

Web-based conferencing. The interviewer took detailed notes and audio recorded each interview.

Verbatim transcripts were generated using a professional transcription service. The interview

guide, along with rationale for each question, are detailed in Appendix D. Before conducting

interviews, the questions were reviewed for clarity and face validity by a PhD prepared nurse

who also meets the criteria for the expert panel. The purpose of the initial round was to generate

a list of types of information critical to decisions regarding the continued need for a CVC or the

need to discontinue a CVC with the aim of preventing CLABSI. CVC management and CLABSI

prevention served as the model case, providing context for the exploration of interprofessional

communication using tEHREHR. Additionally, opinions regarding what channels support the

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exchange of information about CVCs (such aEHRhe EHR, impromptu synchronous exchanges,

scheduled interprofessional rounds, and specialized forms) and factors that promote or inhibit

communicationEHRa the EHR were elicited.

Round One Data Analysis

Directed content analysis was conducted as described by Hsieh and Shannon (2005). This

deductive approach begins with identifying initial coding categories based on concepts or

variables from the guiding theoretical frameworks (Hsieh & Shannon, 2005). According to Hsieh

and Shannon, this approach is suitable when “prior research exists about a phenomenon that is

incomplete or would benefit from further description” (p. 1281). A coding category is “a

descriptive level of content” that describes the “what” of a particular group of data (Graneheim

& Lundman, 2004, p. 107). As a part of the analysis, these categories can be further broken down

into sub-categories (Graneheim & Lundman, 2004).

In directed content analysis, definitions of category codes are derived from the guiding

theories (Hsieh & Shannon, 2005). For this study, the coding categories represented concepts

from the guiding theoretical frameworks of distributed cognition and Coiera’s communication

space (See Appendix H). Definitions included in the description of the theoretical frameworks in

chapter one were used. The categories included: (1) types of information exchanged within the

communication space or activity system; (2) representational states; (3) artifacts; (4) rules and

norms, including common ground, that guide communication behaviors and/or channel selection;

and (5) channel selection for information sharing, including both synchronous and asynchronous

channels. An activity system is “organized by goal-directed behavior” (Hazlehurst et al., 2008, p.

228). In this study, the goal is CVC management and the prevention of CLABSI; therefore, the

focus was on information related to this process.


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When using interviews as a method of data collection, the research questions and probes

should be aligned with concepts from the guiding frameworks to elicit information related to the

selected categories (Hsieh & Shannon, 2005). The interview guide (Appendix D) included

rationale for each question and how it relates to concepts from the guiding frameworks. Once

data were collected and transcribed, the researcher reviewed the interview transcripts and

compared these with the audio recordings to confirm accuracy. Transcripts and typed interview

notes were then be imported into NVivo®, a qualitative analysis software product. The

researcher then went line-by-line through the text and used the predetermined categories to code.

Any data that did not fit into the predetermined categories were noted and considered to

determine if a new category existed or if the data represented a sub-category of the

predetermined codes (Hsieh & Shannon, 2005). To enhance the trustworthiness of the findings,

the definitions for each of the categories were reviewed and agreed upon with one member of the

research team before beginning the coding process (Hsieh & Shannon, 2005). In addition,

category assignments were then verified with the same research team member to confirm coding

decisions. The results of the directed content analysis were used to develop the survey for round

two of the Delphi study.

Round Two Data Collection

The round two survey was sent to participants via an email that contained a link to

REDCap® (see Appendix E for detailed descriptions of each round, and Appendix F for the

proposed timeline). In this round, the survey was divided into three sections. In section one,

participants were asked to rate the relevance of each type of information related to CVC

management and CLABSI prevention identified in round one. Participants also had the

opportunity to add additional items of information and rationale if they deemed it necessary.

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Section two asked participants to indicate what channel was most appropriate for sharing each

type of information. In this section, participants had space to provide a rationale for their

response if desired. The third section of the survey addressed factors that promoted or inhibited

communicatEHR via the EHR. Similar to section one, for each identified factor, participants

rated the relevance of each factor listed. In all three sections, a four-point Likert scale was used.

A four-point scale was chosen to eliminate a neutral response and to illicit responses that indicate

whether an item is relevant or irrelevant, or whether the participant agrees or disagrees with a

statement (Polit, Beck, & Owen, 2007).

Round Two Data Analysis

The aim of data analysis in round two was to organize responses in a meaningful way

(controlled feedback), so that in round three, participants would get a better understanding of the

concepts, areas of agreement or disagreement, and their own assumptions (Linstone & Turoff,

2011). To do this, an individual content validity index, as described in Polit et al. (2007), was

calculated for each item (I-CVI). The I-CVI is a measure of item relevance based on expert

ratings. It is calculated by counting the number of experts that rated an item as a 3 or 4 on a 4-

point scale divided by the total number of experts. Polit and colleagues suggest that an I-CVI of

0.75 or higher, for a panel of 10 or more, is indicative of agreement and is comparable to a

modified kappa rating of excellent, which accounts for the possibility of chance agreement.

Therefore, an I-CVI of 0.75 was used as the cutoff value for determining agreement in this study.

Once I-CVI values were calculated, the round two survey was reproduced for round

three. Items were clearly marked to indicate whether the I-CVI value was above or below the

0.75 cutoff. The survey was then redistributed to participants via email with three things: I-CVI

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values, any comments or rationale from other panel members, and the participant’s previous

response on each item.

Round Three Data Collection and Analysis

In this round, the participants were asked to re-rate each item: they could either verify

their response from the previous round or change their response based on the information

provided regarding the group’s responses. The same procedure as described in round two was

used to analyze responses. Iterations or rounds continued until group conclusions were clear and

there was stability in the panel’s responses. If response rates diminished significantly, the

researcher would have considered eliminating further rounds before stability for all items was

reached, however, this was not an issue as all participants completed all four rounds (Keeney et

al., 2011).

Stability was measured by percent agreement for each item. This was calculated by

counting the number of participants who did not change their response from round to round,

divided by the total number of participants. For example, if there were a total of 18 participants,

and, in round three, 3 participants changed their response on an item from relevant to irrelevant

in round two, 15 participants would have not changed, resulting in 83% agreement (15/18

participants did not change their response). Percent agreement of greater than 80% indicates

stability in responses for a panel of 10 or more (personal communication with M. Heverly, April

19, 2016, Stemler, 2004). It is also important to report on areas of disagreement or divergent

opinions if they emerged, because these are also valuable findings. In some cases, the results

could illustrate two distinct groups of thought, due to having both nurses and physicians on the

panel.

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Data Management Procedure

All notes and transcribed audio recordings were stored on the researcher’s encrypted and

password-protected computer. Before transcription, the researcher removed all personally

identifiable information. All notes and audio files were assigned a unique code number to protect

the identity of participants. A separate file that linked the participant to the number code was

stored in a second location on the researcher’s encrypted and password protected computer.

Identifying the participants’ responses by a code was necessary in order for the researcher to

provide individualized feedback during subsequent rounds of the study. Surveys were conducted

using REDcap®, which is a secure Web-based application. Data will be stored for up to 5 years

after completion of the study or as required by the IRBs.

Rigor

Just as there are no definitive guidelines for conducting a Delphi study, there are also no

clearly identified criteria for determining rigor. To fill this void, Diamond et al. (2014) proposed

four quality indicators for evaluating the application of the Delphi method based on their review

of 100 published studies. These indicators include: a priori criteria for stopping, planned number

of rounds, reproducible criteria for the selection of the panel, and clear criteria for dropping

items at each round (Diamond et al., 2014). The methods described in this chapter have

addressed each of these quality indicators and how these issues were managed in this study. To

summarize briefly, stability of responses, as measured by percent agreement, was identified as

the a priori stopping criteria; it was anticipated that three to four rounds would be needed to

reach stability and ultimately four rounds were needed; inclusion criteria for panel participants

were explicitly described; and the use of the I-CVI with a cutoff value of 0.75 was set as the

criterion for dropping items.


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In addition to the above quality indicators, criteria for rigor in qualitative research was

also addressed. Issues of trustworthiness, such as credibility, transferability, confirmability, and

dependability are described here. Credibility is concerned with how accurately the findings

represent truth as perceived by the participants in the context of the study (Krefting, 1991). Due

to iterative rounds in the Delphi method, responses were verified continuously by the

participants, thus enhancing credibility. Transferability refers to the extension of findings to

another context (Krefting, 1991). Transferability is a quality that should be determined by a

person outside of the study; it is dependent on detailed descriptions of the data and information

regarding the context and participant demographics, all of which were reported in this study

(Krefting, 1991). Confirmability is strengthened when bias is reduced. In this study, the

researcher maintained a journal throughout the data collection and analysis process in order to

reflect on and attempt to set aside any personal judgments or assumptions. In addition, an audit

trail that includes raw data, description of procedures, and decisions made by the researcher

throughout the conduct of the study, were maintained as a way to enhance confirmability (Polit

& Beck, 2012). Lastly, dependability, which pertains to the reliability of the findings, is attended

to by addressing the quality indicators described by Diamond et al. (2014).

Regarding issues of rigor, it is important to reiterate that the purpose of the Delphi is to

elicit informed judgments from a group of relative experts, not to arrive at statistically supported

findings. Furthermore, these findings from the Delphi method are reflective of the emic

perspective (the perceptions of the panel) and dependent on contextual variables as in qualitative

research. Therefore, results should be viewed and interpreted through this lens.

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Chapter Four: Introduction

This chapter presents results from the four rounds of a Delphi study to describe what

nurses and physicians believe regarding how the EHR ought to be used to optimize

interprofessional communication concerning ventral venous catheter (CVC) management and the

prevention of central line–associated blood stream infections (CLABSI). The chapter begins with

a description of the demographics of the members of the expert panel. Next, the results are

presented for each of the four Delphi rounds, including how the results from each round

impacted the subsequent round. Lastly, the results are summarized as they relate to the research

questions.

Description of Sample

The expert panel was comprised of 10 healthcare professionals working within the

Partners Healthcare System, a Boston, non-profit hospital and physician network. Six of the

panel members were nurses, and four were physicians. See Table 1 for additional details

regarding the participants’ demographics, practice setting, and level of experience. The panel

was well balanced with two nurse leaders, one physician leader, and seven practicing clinicians

whose experience ranged from one to 20+ years in practice and in working with an EHR. The

majority of the panel participants worked at a large academic teaching hospital, and seven out of

the 10 worked outside the intensive care unit (ICU) in acute care. This last characteristic,

working outside the ICU, is noteworthy— as communicating through the EHR becomes more

critical in a non-ICU setting where physicians and nurses do not work in close proximity at all

times. Sixty percent of the participants reported caring for nine or more patients with CVCs in

the past month.


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Table 1




"



Demographic Characteristic n %
Female 4 40%
Gender
Male 6 60%
18 to 23 0 0%
24 to 29 3 30%
30 to 35 1 10%
36 to 41 1 10%
Age
42 to 47 1 10%
48 to 53 1 10%
54 to 59 3 30%
> 59 0 0%
White 8 80%
Hispanic or Latino 1 10%
Black or African American 0 0%
Ethnicity
Native American or American Indian 0 0%
Asian/Pacific Islander 1 10%
Other 0 0%
Nursing 6 60%
Profession Medicine 4 40%
Other 0 0%
Associate's degree 0 0%
Bachelor's degree 5 50%
Education Master's degree 1 10%
Doctoral degree 3 30%
Post-doctoral studies 1 10%
1 to 3 years 2 20%
4 to 9 years 2 20%
Years Since Initial
Licensure 10 to 15 years 2 20%
16 to 20 years 0 0%
> 20 years 4 40%

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Demographic Characteristic n %
Staff nurse 4 40%
Nurse leader: nurse educator, nurse in charge 2 20%
Resident 2 20%
Role Fellow 0 0%
Attending 1 10%
Physician leader: Medical director and practicing 1 10%
physician
Large academic teaching hospital 8 80%
Institution Type Community hospital 1 10%
Other: Teaching community hospital 1 10%
Intensive care 3 30%
Acute care, outside of the intensive care unit 7 70%
Practice Setting
Outpatient setting 0 0%
Other 0 0%
0 to 12 hours 0 0%
13 to 24 hours 1 10%
Hours Worked Per
Week 25 to 36 hours 4 40%
37 to 45 hours 2 20%
> 45 hours 3 30%
Less than 3 4 40%
Number of Patients 4 to 8 0 0%
with CVCs in Past 9 to 12 3 30%
Month 12 to 15 2 20%
More than 15 1 10%
Yes 6 60%
Institution Using
CLABSI Bundle No 1 10%
Not sure 3 30%
< 1 year 0 0%
1 to 3 years 4 40%
Years of Experience 4 to 10 years 3 30%
with EHR 11 to 15 years 2 20%
16 to 20 years 0 0%
> 20 years 1 10%

DA

IRB Approval

Prior to recruitment of the expert panel, IRB approval was sought from Partners

Healthcare System, and the IRB determined that the study was exempt. Newton Wellesley

Hospital (NWH), although within the Partners healthcare system, required review by their own

IRB. Therefore, the study proposal was submitted to NWH. NWH IRB’s decision was to cede

review and accept Partners Healthcare’s IRB exempt status. Approval was also sought and

obtained from the Villanova University IRB to analyze de-identified data. The Villanova IRB

designated this study as exempt.

Recruitment

Healthcare professionals were recruited through email solicitation. Clinicians identified

by key informants from the three target institutions were sent a brief introductory e-mail that

gave an overview of the study and included the criteria for expert panel members. The key

informants were clinical informaticians and administrative leaders. The e-mail requested that

interested participants, who met the panel criteria, respond via e-mail indicating their interest. In

addition, snowball sampling was employed whereby potential participants were encouraged to

forward the initial recruitment e-mail to colleagues whom they thought might be interested and

fit the criteria.

When interested participants responded via e-mail, a formal recruitment e-mail was sent

out. See Appendix B. Within the recruitment e-mail, there was with an individual link to

REDCap, a secure Web application used for survey development, associated with a unique

participant identifier. This REDCap link included the consent for participation and the initial

demographic survey. Recruitment was conducted between December 2016 and February 2017.

DB

After panel members completed the consent and demographic survey, individual

interviews were scheduled and conducted. Interviews took place over a six-week period between

December 2016 and February 2017. Interviews were audio recorded and then transcribed

verbatim three to four at a time by a professional transcription service throughout the Round 1

interview period. This allowed the researcher to review the transcripts and verify them for

accuracy on a rolling basis, which in turn informed the ongoing interviews and provided a means

for determining when saturation was reached. All verified transcripts were imported into

NVivo® for analysis.

Throughout the recruitment period, there was a concerted effort to obtain a representative

sample of practice settings within the three different study sites while maintaining a balance

between the number of nurses and physicians. Several attempts were made, through key

informants and snowball sampling, to recruit clinicians from the intravenous therapy (IV) team.

Although the investigator was unable to enroll any IV therapy clinicians, the sample size of 10

minimally met the requirements for analysis using the I-CVI calculation as described by Polit,

Beck, and Owen (2007) for content validity.

Panel Response and Attrition

All 10 panel members completed all four Delphi rounds with one exception. One of the

panel members who participated in the Round 1 interviews took a leave of absence just as the

Round 2 surveys were sent out. Another clinician, from the same professional group (physician)

and setting, who could not participate during the Round 1 interviews joined the panel at the start

of Round 2. Thus, although one participant left and one joined, the overall make-up of the panel

in regards to experience, practice setting, and expertise remained unchanged. There was no

further attrition in the remaining three survey rounds.


DC

Delphi Data Analysis

Summary of Round 1 Results and Implications for Round 2

Free text narrative data from the Round 1 interviews were analyzed using directed

content analysis (Hsieh & Shannon, 2005), one approach within the broader method of

qualitative content analysis. Hsieh and Shannon define content analysis as “the subjective

interpretation of the content of text data [free text narrative data] through the systematic

classification process of coding and identify themes or patterns” (2005, p. 1278). What

distinguishes directed content analysis from other forms of content analysis is the use of existing

theoretical frameworks or theories in establishing a coding framework with the aim of extending

or building upon existing theoretical frameworks (Hsieh & Shannon, 2005).

In keeping with this method, concepts from the two guiding theoretical frameworks for

this study, distributed cognition and Coiera’s communication space, (see Figure 1 and 2) were

used to develop a coding framework. The coding framework included a structure of categories

and subcategories, as well as definitions for each category derived from the theoretical

frameworks (See Appendix H). Once this framework was developed, it was reviewed, revised,

and confirmed with another member of the research team (SC).

The coding framework was used to categorize and label excerpts from the narrative data

for each verified transcript that had been imported into NVivo®. Coding was done in a stepwise

manner. Initially, two nodes were established in NVivo® to represent the two main categories

within the coding framework, “information type” and “factors that influence use of EHR for

communication.” As each transcript was read, all identified information types were highlighted

and placed in the corresponding node. Concurrently, all factors that influence use of EHR for

communication were highlighted and categorized in the same manner. As information types were

DD

identified, narrative data excerpts were further labeled descriptively and coded to indicate the

information within the excerpt. For example, several participants discussed the importance of

knowing whether it is possible to obtain other peripheral IV access or whether it has been

difficult in the past to obtain peripheral IV access for a particular patient. This information type

was labeled or coded as “difficulty getting peripheral venous access,” and all related data

excerpts were added to this descriptive code under the category of information type. This process

continued iteratively, and the descriptive labels for each code were reviewed and modified as

needed after all of the transcripts had been coded.

The second node, factors that influence use of EHR for communication, resulted in a

category that included factors that both inhibit and promote the use of the EHR for

communication among the interprofessional team. After coding all transcripts for possible factors

that inhibit or promote the use of the EHR, this list was re-read and sorted into two sub-nodes—

factors that promote or factors that inhibit. Once these data excerpts were separated into factors

that promote and factors that inhibit, they were re-read and descriptive labels or codes were

created for each factor. These descriptive labels were used to create items for Section III of the

Round 2 survey.

Next, the data coded for information type and the related data extracts were revisited. For

each information type, two additional sub-nodes were created in NVivo® consistent with the

concepts in the coding framework. The first indicated where the information is found, which

represents the artifact and representational state. The second indicated how the information is

communicated, which represents the channel. The “how” sub-node was further divided into

channels that are currently used to communicate an information type and channels that should be

used to communicate an information type. In both cases, the channel could be either

DE

asynchronous or synchronous, and it was labeled and coded as such. If panel members provided

rationale for the use of a particular channel, this was labeled and coded as a rule or norm

representing the why for using a particular method of communication. For any one information

type, there might be several possible channels or representational states. Throughout this process,

a few general rules or norms were identified that did not apply to a specific information type, and

these were placed within a node labeled or coded general rules or norms.

Once analyzed, the data from the Round 1 interviews served as the basis for the

development of the Round 2 survey. The Round 2 survey was built as described in the methods

section of chapter 3 (see Appendix E). This survey structure was submitted to the Partner’s IRB

for approval before recruitment began.

Survey Section I: Information types. The survey had three sections. The full Round 2

survey is included as Appendix I. The first section was designed to allow panel members to

review a list of information types derived from the interviews in Round 1. For each information

type, participants indicated whether the information type is relevant to decisions to keep or

remove a CVC. All information types identified and descriptively labeled from the interview

transcripts were included in Section I of the survey for the subsequent Delphi rounds with the

following exceptions. First, there were several information types related to medications. The

related data extracts from the transcripts were reviewed for each of the medication-related

information types, and a decision was made to aggregate these into one item for the Section I

survey. Second, Central Venous Pressure (CVP) monitoring was mentioned by only one

participant, and there was little discussion about the importance of this information and how it

should be communicated to the healthcare team. This is consistent with previous research that

found that CVP monitoring alone would not be a reason to keep a CVC in place (Thate et al.,

E<

2016). Furthermore, CVP monitoring is not done outside the ICU. For these reasons, CVP was

not included in the information type list for this Delphi survey. There was, however, a space for

participants to add in information types not included in the survey, thus allowing them to add

information related to CVP monitoring or other information they felt relevant to decisions

regarding CVC decisions.

Survey Section II: Communication Channel selection. The second section of the

survey aimed to solicit panel members’ opinions regarding the appropriate communication

channel for sharing each type of information included in Section I with the interprofessional

team. Each statement in this section included the artifact or representational state where the

information might be found along with the synchronous or asynchronous channel (see Appendix

I). For example, Section II item 1a reads, “The conditions under which the central venous

catheter line was placed is best communicated through the EHR in a documentation form such

as, in the procedure note.” “Conditions under which the central venous catheter line was placed”

represents the information type. “Through the EHR” represents the communication channel, and

in this case, the channel is asynchronous. Lastly, “Documentation form, such as in the procedure

note” indicates the artifact or representational state. These statements were taken directly from

the analysis of the Round 1 interviews and reflect the categories described in the directed coding

framework. For each of the statements in Section II, participants indicated agreement or

disagreement rather than relevant or not relevant to reflect their opinion regarding the method of

communication.

Section III: Factors that promote or inhibit. The third and final section of the survey

explored factors that promote or inhibit the use of the EHR for communication and information

sharing among the interprofessional team. For these statements, participants indicated whether or

E=

not the factor was relevant, thus expressing their opinion regarding whether this factor inhibited

or promoted their use of the EHR for communication among the interprofessional team. Each of

the statements in Section III were taken directly from the corresponding categories within

NVivo® from the analysis of the Round 1 interviews.

Once the survey was complete, including directions for each section, this draft was

reviewed by all members of the research team. Intensive review was done by one member (SC).

Feedback and revisions from the research team aimed at increasing the clarity of statements were

provided and incorporated into the final survey.

Summary of Round 2 Results and Implications for Round 3

In Round 2, all 10 panel members completed the survey within 1 week. This was

desirable because it was important to keep survey rounds as abbreviated as possible to keep

panel members engaged and to prevent attrition (Keeney et al., 2011). Survey results were

analyzed using Excel. Consensus regarding relevancy or agreement was measured by calculating

the item-level content validity index (I-CVI) value for each item or question in the survey. Polit,

Beck and Owen (2007) define the CVI as “an index of inter-rater agreement” (p. 461). The I-CVI

is therefore an index of inter-rater agreement for an individual item. Items with an I-CVI greater

than or equal to 0.75, for a group of 10 or more, are deemed relevant and are comparable to a

kappa rating of excellent which accounts for chance agreement (Polit et al., 2007).

Results by survey section for Round 2. In Section I, there were 12 information types

listed. Out of the 12, seven of the items had an I-CVI value of 1.00, indicating complete

agreement that these items were relevant to decisions regarding whether to keep or discontinue a

CVC. (See Table 2) Three items had an I-CVC of 0.9, and one item had an I-CVI of 0.8. Thus in

sum, 11 items of the 12 were found to be relevant because they were above the cut off I-CVC

E>

value of 0.75. One item, “reason the CVC was initially placed”, had an I-CVI of 0.70, thus

falling below 0.75, indicating that there was not consensus that this information is relevant to

decisions regarding whether to keep or discontinue a CVC. None of the panel members added

any additional information types in the space provided in Section I. For six of the items in

Section I, panel members provided comments or rationale for their responses. Both the prompt

response to the surveys and the inclusion of rationale by participants demonstrates engagement

in the process, an important aspect of a successful Delphi study.


E?

Table 2

 
%


 

Information Type I-CVI Rationale

Conditions under which the CVC was 1.0 Access can be key to provide
placed (e.g., emergently in the ED) emergent medications and access labs.

Difficulty getting peripheral venous access 1.0

Evidence of infection (e.g., fever, rising 1.0
WBC)
Frequent blood draws 0.8 Depends on the decision of frequent
and what other ways one is doing the
blood draws.
Only if there is no alternative method
to draw blood.

Functioning of the CVC (i.e., ability to
flush and draw back blood)
Location of the CVC (e.g., IJ, SC, Femoral)
1.0 If not working, will always pull it.
1.0 Most relevant for femoral lines. We
like to keep those only for 24 hours.
Particularly if it was placed under less
than ideal conditions.
More likely to pull femoral.

Number of intravenous medications being 0.9

administered and whether they require
central administration
Number of days CVC has been in place 0.9
Presence of other venous access 1.0
CVC insertion site condition 0.9 If looks bad, it is helpful. But
otherwise not that helpful.
Reason the CVC was initially placed 0.7
What the CVC is currently being used for 1.0 If conditions no longer met i.e., meds,
monitoring, labs.

E@

In Section II, each information type included up to four options or channels for

communicating the information among an interprofessional team of nurses and physicians. The

options, which included the channel and the artifact or representational state, were taken directly

from the analysis of the Round 1 interview. In addition to the options provided, there was also

space for participants to add other channels or methods. For six of the information types,

comments were provided from the panel members regarding other methods or channels to

communicate. (See Table 3).

Table 3

 
%


 

Type & Channel
Conditions under which the central venous line was placed would be most effectively
communicated with the interprofessional team
through the procedure note.
through the physician's progress note.
through the nurse's progress note.
using a communication messaging tool (e.g.,
an electronic sticky note).
Other channel (please specify).
I-
Rationale
CVI
0.9 Not most effective- not easily
accepted or searched.
0.6 Notoriously unreliable, unclear
which CVC referring to, not a
natural place to look.
Very busy notes- would be difficult
to find most relevant information.
0.5 Not always.
Not a natural place to look.
Not read by all participating
disciplines.
0.6 Through the EHR's IV
documentation. When, where and
how it was placed should be
documented there.
Not always.
Not a natural place to look.
Accessible to all teams, though
sticky notes may not save to record.
#N/A Can also be in patient's room and
appropriately communicated or

EA

I-
Type & Channel Rationale
CVI
demonstrated. Could be something
also outside the EHR and traditional
entities that could complement its
use.
In the IV documentation section in
the EHR.
In the access report in Epic.
Difficulty getting peripheral venous access is something that the bedside nurse or IV nurse would
know from their assessment, and this is not reliably documented in the EHR. This information
would be most effectively communicated with the interprofessional team.
through the EHR in a documentation tool 0.8 Hard to find it there.
(e.g., in the IV assessment flowsheet with Nursing flowsheets not reviewed by
fields that capture date of last attempt to team.
place peripheral IV, number of attempts by
the bedside nurse, number of attempts by the
IV nurse).

orally during interprofessional team rounds. 0.9 Could be noted, but needs to be part
of record.
orally as soon as it is noted. 1.0 Not immediately.
Hard to ensure this gets passed on.
Should also be written.
other channel (please specify). #N/A From RN when discussing CVC on
rounds.
Evidence of an infection may be based on patient temperature, lab results, and assessment of the
CVC insertion site. This information would be most effectively communicated with the
interprofessional team.
orally as soon as there is a concern. 1.0 As well as written.
orally during interprofessional team rounds. 0.9 May be hours after start of infection-
could have earlier intervention if
noted straight away.
through the lab results. 0.6 May not be interpreted
correctly/viewed.
through the vital signs flowsheet. 0.7 If one can see signs of sepsis from
the vital signs, but not clearly should
be communicated here. Visible to
RN's and physicians.
other channel (please specify). #N/A Any form of communication or
manner that such initiatives are

EB

I-
Type & Channel Rationale
CVI
highlighted at a hospital.

The need for frequent blood draws would be most effectively communicated with the
interprofessional team.
orally during interprofessional team rounds. 0.8 Should be mentioned, but also
documented.
through the provider order entry tool. 0.7 Not sure how this would help.
Should be easily visible/accessible.
other channel (please specify). #N/A Notes and other communication
channels.
The functioning of the CVC, including whether the line can be flushed or if blood can be drawn,
would be most effectively communicated with the interprofessional team.
through the IV assessment flowsheet. 0.8 Docs probably would not look here.
Not a natural place to look.
MDs don't always view these
flowsheets- especially nursing
assessments.

orally during interprofessional team rounds. 0.9 Should be discussed, but also
documented.
other channel (please specify). #N/A
The location of the CVC (subclavian, internal jugular, femoral) would be most effectively
communicated with the interprofessional team.
through the IV assessment flowsheet. 0.9
through a patient level summary view (e.g., 1.0
the summary screen that pulls data from a
procedure note or IV assessment flowsheet).

orally during interprofessional team rounds. 0.9 Usually not necessary.

other channel (please specify). #N/A

Number of intravenous medications that are being administered and whether they require central
administration would be most effectively communicated with the interprofessional team.
by flagging medications in the medication 0.7 Good place for the nurse...not
administration record (MAR) if they require necessarily anyone else.
central administration.

EC

I-
Type & Channel Rationale
CVI
by including the site of administration on the 0.5 Doesn't help us now.
MAR for each medication (e.g., the time of Changes frequently.
last administration of any IV medication
would include the port and site of
administration, such as, right, internal
jugular, proximal port or right forearm
peripheral IV.)

orally during interprofessional team rounds. 0.8

other channel (please specify). #N/A
Number of days a CVC has been in place would be most effectively communicated with the
interprofessional team.
through a patient level summary view (e.g., 1.0
the summary screen or patient dashboard
that pulls data from the IV assessment
flowsheet or procedure note).
other channel (please specify). #N/A Interprofessional rounds.
During rounds we usually give
device days.
The availability of other IV access would be most effectively communicated with the
interprofessional team.
through the IV assessment flowsheet. 0.8 But in a way that it is easily
understood and visible and therefore
easily communicated. Only helpful
if pt. has been referred.
through a patient level summary view of all 0.9
the tubes, drains, and airways.
other channel (please specify). #N/A
The condition of the CVC site would be most effectively communicated with the
interprofessional team.
through the IV assessment flowsheet. 0.8 Most effectively should be orally.
May not be seen by MDs.
orally as soon as a change is noted. 1.0 Should be documented as well.
other channel (please specify). #N/A Or by whatever the mechanism to
ensure that communication is
occurring through team members.

ED

I-
Type & Channel Rationale
CVI
The reason the CVC was placed would be most effectively communicated with the
interprofessional team.
through the procedure note. 0.9 Not always easily accessible info.
through the IV assessment flowsheet. 0.8 Not always seen by MDs.
other channel (please specify). #N/A
What the CVC is currently being used for would be most effectively communicated with the
interprofessional team. For this to be shared via the EHR, it would require clinicians to document
current reason for use daily or for each shift.
through a patient level summary view (e.g., 0.8
the patient safety dashboard).
through the IV assessment flowsheet. 0.8
orally during interprofessional team rounds. 0.9 Only if relevant to discussion on
rounds.
other channel (please specify). #N/A
Note. The term “patient level summary view” is used to describe a general concept, and it is
important to note that this could take many forms and may be configured differently for different
clinicians.

For each of the information types in Section II, there was at least one channel or

communication method that had an I-CVI above 0.75, indicating agreement that there was an

effective way to communicate this particular piece of information. For some information types,

up to three channels or methods had an I-CVI above 0.75, indicating that more than one channel

should or could be used to communicate this information type. (See Table 3 for related results).

In Section III—factors that promote or inhibit the use of the EHR for communication or

information sharing—participants were presented with a list of items derived directly from the

Round 1 interviews. For each of the items, the participants rated whether the statement was

relevant to promoting or inhibiting the use of the EHR for communication and information

sharing. For factors that promote, all 11 items had an I-CVI greater than 0.75, indicating that all

of the factors were deemed relevant by the panel; in other words, they are factors that promote

EE

the use of the EHR. In addition, there was one comment in the section for “other factors” that

promote EHR use (see Table 4 for detailed results). For factors that inhibit, there were 14 items

derived directly from the Round 1 interview. Eight out of the 14 statements had an I-CVI greater

than 0.75, whereas six had an I-CVI below 0.75. In addition, there was one comment in the

“other factors that inhibit” area (see Table 5 see detailed results).

Table 4

 
%



 

I-
Promote Use of EHR
CVI
The number of years of experience an individual has using an EHR. 1.0
The availability of summary views such as dashboards or patient level summary 1.0
screens.
The ability to prompt or draw attention to specific information, such as ability to 1.0
highlight an item on a flowsheet.
The accessibility of the EHR so that it can be viewed by anyone at any time. 1.0
A search feature that allows clinicians to find specific information. 1.0
The presence of a summary or overview as found in narrative notes. 0.8
An individual's comfort level with technology. 1.0
The need to find specific details and data about a patient. 0.9
I know the information might be needed at a later date as a reference. 0.8
I can more easily view trends. 1.0
I am more apt to use the EHR to share information with someone in my discipline 0.8
(nurse to nurse, physician to physician).
Other factors that promote the use of the EHR for communication (please specify):
How well the EHR is created for user functionality and workflow and how well
this is communicated to those learning how to use the EHRs.

=<<

Table 5

 
%



 

Inhibit Use of EHR I-CVI

It is too difficult to find the information I am looking for. 0.8
The same information might be in multiple places. 1.0
It is faster to 'go ask someone.’ 0.8
Lack of knowledge on how to use EHR. 0.8
I don't know the workflow of other clinicians and therefore don't know 0.8
where to look for certain types of information.
Information is not accurate due to 'copy and paste' functionality. 0.6
The relevant information is not in the EHR. 0.7
The EHR is not up-to-date. 0.8
I can't have a discussion in the EHR. 0.5
I can't confirm that information has been received. 0.8
I can't highlight what is important. 0.6
I am working in close physical proximity to other care team members so we 0.9
can have a discussion instead.
I don't know the workflow of other clinicians, and therefore I am not certain 0.7
that other clinicians will be able to view the information that I documented.
It takes too many "clicks" to find the information I am looking for. 0.7
Other factors that inhibit the use of the EHR for communication (please specify):
difficult to obtain reports

Implications for Round 3. The Round 2 survey was used as the basis for the

development of the Round 3 survey. All of the items from Round 2 were included in Round 3

with the following additions and modifications. First, the directions were updated in each section

of the survey to describe how the results from Round 2 were being presented and to make it clear

=<=

that the participants were being asked to re-rate each item while considering the responses of the

other panel members provided. Second, the I-CVI value was converted to a percent and was

included below each item along with any rationale or comments provided by the panel members.

(See survey Round 3 in Appendix J.) Third, if an item fell below an I-CVI of 0.75, this item was

highlighted in yellow. Participants were informed in the directions that the highlighted questions

represented items deemed not relevant by the group or for Section II, channels that were not an

agreed upon method for communicating a particular information type. Again, no items were

removed from the original Round 2 survey for Round 3. In addition to the I-CVI values, each

participant was sent a table that included their own responses and comments for each item in the

Round 2 survey. This allowed participants to review the rating of the group alongside their own

response as they re-rated items in the Round 3 survey.

Summary of Round 3 Results and Implications for Round 4

The Round 3 survey was sent to all 10 panel members a week and a half after the Round

2 survey was sent. Reminders were sent every 3 to 4 days to those who had not yet completed the

survey. All of the Round 3 surveys were completed and returned in approximately 3 weeks.

Responses were once again analyzed in Excel, and I-CVI values were re-calculated for each

item.

In addition to the I-CVI values, individual percent agreement was calculated for each

item. This metric represents the number of participants who did not change their response from a

rating of 1 or 2 (not relevant or disagree) to 3 or 4 (relevant or agree) or vice versa thus

indicating item stability. Item stability can be defined as the percent of participants who did not

change their response pertaining to relevancy or agreement from round to round.


=<>

The target for percent agreement or stability was set at 80%. This equates to two out of

the 10 panel members changing their rating from a negative to positive or vice versa on the

dichotomous scale. This level of change or percent agreement was the a priori stopping criteria

because this would indicate stability in responses. Any item with a percent agreement greater

than 80% was considered stable, and for these items, the I-CVI value was considered the panel’s

final answer. Just as in Round 2, any item with an I-CVI value greater than 0.75 was considered

relevant or agree, and any item below 0.75 was considered not relevant or disagree. After closer

review, a few of the stable items were identified as needing further analysis based on the criteria

described below.

All items that were unstable (percent agreement less than 80%) were considered as

potential items for the Round 4 survey and individually reviewed with the research team. To aid

in the analysis, a condition statement was added in Excel to indicate whether the group

consensus had changed from an overall rating of relevant to not relevant or agree to disagree

(and vice versa). This was noted by a "true" or "false" next to each item. (See Table 6). True

indicated that the group consensus had flipped categories, whereas false indicated that there was

no change in relevancy or agreement for this item. Unstable items that “flipped” or moved from

relevant to not relevant as indicated by “true” were initially interpreted to need further

information from the group to determine final consensus. However, based on discussion with the

research team, the following criteria were used to determine what items needed to be re-

evaluated in the Round 4 survey.


=<?

Table 6

 
&


 

R2 R3
Relevance R4
Information Type Rationale I- I- Stability
changed Criteria
CVI CVI
Conditions under 1.0 1.0 FALSE 100%
which the CVC was
placed (e.g.,
emergently in the
ED)

Difficulty getting 1.0 1.0 FALSE 100%

peripheral venous
access
Evidence of 1.0 1.0 FALSE 100%
infection (e.g.,
fever, rising WBC)
Frequent blood 0.8 0.8 FALSE 100%
draws
Functioning of the 1.0 1.0 FALSE 100%
CVC (i.e., ability to
flush and draw back
blood)
Location of the was more relevant at 1.0 1.0 FALSE 100%
CVC (e.g., IJ, SC, one time, but there
Femoral) does not seem to be
any reason not to at
least get someone
OOB with a femoral
line in years past there
was a push against
doing so
Number of 0.9 1.0 FALSE 90%
intravenous
medications being
administered and
whether they
require central
administration

=<@

R2 R3
Relevance R4
Information Type Rationale I- I- Stability
changed Criteria
CVI CVI
Number of day increased device days 0.9 0.9 FALSE 80%
CVC has been in increases potential for
place CLABSI
Presence of other 1.0 1.0 FALSE 100%
venous access
CVC insertion site bad site condition 0.9 1.0 FALSE 90%
condition adds to the impetus to
remove
Reason the CVC 0.7 0.7 FALSE 60% 3
was initially placeda
What the CVC is monitoring, blood 1.0 1.0 FALSE 100%
currently being used drawn, TPN
for
Other information #N/A #N/A #N/A #N/A
type not included
above (please
specify)

a
signifies items to be included on the Round 4 Survey
The author, with input from the research team, determined that further input from the

panel was needed for:

1) any item that changed relevancy from Round 2 to Round 3 (marked as “True”),

2) any item that was unstable (percent agreement less than 80%) and moved from

irrelevant towards relevant (This is important because the goal was to determine what

items are relevant.), and

3) any item that was unstable and had a borderline I-CVI value (0.7 or 0.8) in Round 3.

Regardless of stability, items were not included in Round 4 if group consensus regarding item

relevancy was clear (clearly relevant or clearly irrelevant/clearly agree or clearly disagree). For

example, under “the need for frequent blood draws” and “through the provider order entry tool,”

=<A

the I-CVI in Section II for Round 2 was 0.7 (irrelevant) and the I-CVI in Round 3 was 0.5 (more

irrelevant). (See Table 7.) Although there was instability, it was clear that the group had deemed

this item irrelevant, and therefore, there was no reason to re-query the group regarding this item.

Results by survey section. In Section I, information type, in Round 3 just as in Round 2,

11 of the 12 items had an I-CVI above 0.75, thus indicating agreement regarding the relevance of

these items. (See Table 6). There were no items in this section that changed pertaining to the

relevance. Therefore, the same 11 items from Round 1 were deemed relevant information types

by the panel, and one item, “reason the CVC was initially placed,” was deemed not relevant to

decisions regarding whether to continue or discontinue a CVC. Although there were no items

that changed relevancy, one item, “reason the CVC was initially placed,” was unstable with a

percent agreement of 60%. Based on the aforementioned criteria (rule 3), this item was added to

the Round 4 survey to seek further clarification on the panel’s opinion.

For Section II, type and channel, only one item representing a particular communication

channel for an information type changed relevancy. This is indicated in Table 7 and is marked as

true. Instances where the I-CVI was unchanged from Round 2 to Round 3 but the stability was

less than 100%, indicated panel members changing their rating in a way that did not alter the

Round 3 I-CVI. For example, in the first line of Table 7, one panel member changed their rating

from 4 to 2 and another from a 1 to a 3. Thus, the final I-CVI was unchanged because these two

panel members flip flopped (80% stability) regarding the relevancy of the statement. In addition,

there were a total of nine unstable items. Each of these items were reviewed using the

aforementioned criteria. Four of these items, although unstable, moved from an I-CVI value of

less than 0.75 to an even lower I-CVC, indicating clear consensus that this item did not represent

a viable channel for communicating the particular information type. Three of the unstable items

=<B

moved from an I-CVI greater than 0.75 to a larger I-CVI, thus indicating clear consensus or

agreement that this channel is believed to be effective for communicating the particular

information type. The remaining two unstable items in Section II were marked for inclusion in

the Round 4 survey (denoted by the letter a). Of these two items, one changed relevancy from

Round 2 to 3 and the other was moving towards “agree.”

Table 7

 
&


 

R2 R3 Relevance R4
Type & Channel Rationale Stability
I-CVI I-CVI changed Criteria
Conditions under which the central venous line was placed
through the 0.9 0.9 FALSE 80%
procedure note.
through the 0.6 0.5 FALSE 90%
physician's
progress note.
through the Nurse's note is 0.5 0.3 FALSE 60%
nurse's progress not always the
note. primary source
an
interprofesional
team would
look to for
overall
information and
therefore I
would not call it
the most
effective place
to communicate
central line info.

=<C

R2 R3 Relevance R4
Type & Channel Rationale Stability
I-CVI I-CVI changed Criteria
using a Depends on the 0.6 0.6 FALSE 80%
communication environment of
messaging tool the institution.
(e.g., an
electronic sticky
note).

other channel none provided

(please specify).
Difficulty getting peripheral venous access
through the EHR I am not 0.8 1.0 FALSE 80%
in a familiar with
documentation such a
tool (e.g., in the documentation
IV assessment tool that has
flowsheet with such IV
fields that capture assessment
date of last flowsheets that
attempt to place clearly
peripheral IV, document this
number of clearly.
attempts by the
bedside nurse,
number of
attempts by the
IV nurse).
orally during best way during 0.9 0.9 FALSE 100%
interprofessional rounds
team rounds.
orally as soon as 1.0 1.0 FALSE 100%
it is noted.
other channel none provided
(please specify).
Evidence of an infection
orally as soon as 1.0 1.0 FALSE 100%
there is a
concern.
orally during 0.9 0.9 FALSE 100%
interprofessional
team rounds.

=<D

R2 R3 Relevance R4
Type & Channel Rationale Stability
I-CVI I-CVI changed Criteria
through the lab 0.6 0.5 FALSE 70%
results.
through the vital 0.7 0.4 FALSE 70%
signs flowsheet.
other channel none provided
(please specify).
The need for frequent blood draws
orally during 0.8 0.9 FALSE 90%
interprofessional
team rounds.
through the 0.7 0.5 FALSE 60%
provider order
entry tool.
other channel none provided
(please specify).
The functioning of the CVC
through the IV I am not 0.8 0.9 FALSE 70%
assessment familiar with
flowsheet. which IV
assessment
flowsheet

orally during or even before 0.9 0.9 FALSE 100%

interprofessional rounds if the
team rounds. appropriate
providers are
available

other channel none provided

(please specify).
The location of the CVC (subclavian, internal jugular, femoral)
through the IV 0.9 1.0 FALSE 90%
assessment
flowsheet.

=<E

R2 R3 Relevance R4
Type & Channel Rationale Stability
I-CVI I-CVI changed Criteria
through a patient 1.0 1.0 FALSE 100%
level summary
view (e.g., the
summary screen
that pulls data
from a procedure
note or IV
assessment
flowsheet).

orally during 0.9 0.8 FALSE 90%

interprofessional
team rounds.
other channel none provided
(please specify).
Number of intravenous medications that are being administered and whether they require
central administration
by flagging 0.7 0.8 TRUE 70% 1, 3
medications in
the medication
administration
record (MAR) if
they require
central
administration. a

==<

R2 R3 Relevance R4
Type & Channel Rationale Stability
I-CVI I-CVI changed Criteria
by including the 0.5 0.7 FALSE 60% 2, 3
site of
administration on
the MAR for
each medication
(e.g., the time of
last
administration of
any IV
medication would
include the port
and site of
administration,
such as, right,
internal jugular,
proximal port or
right forearm
peripheral IV.) a

orally during 0.8 0.9 FALSE 70%

interprofessional
team rounds.
other channel none provided
(please specify).
Number of days a CVC has been in place
through a patient 1.0 1.0 FALSE 100%
level summary
view (e.g., the
summary screen
or patient
dashboard that
pulls data from
the IV
assessment
flowsheet or
procedure note).

other channel none provided

(please specify).

The availability of other IV access


===

R2 R3 Relevance R4
Type & Channel Rationale Stability
I-CVI I-CVI changed Criteria
through the IV 0.8 0.9 FALSE 90%
assessment
flowsheet.
through a patient 0.9 1.0 FALSE 90%
level summary
view of all the
tubes, drains, and
airways.

other channel none provided

(please specify).
The condition of the CVC site
through the IV 0.8 0.9 FALSE 70%
assessment
flowsheet.
orally as soon as 1.0 1.0 FALSE 100%
a change is noted.

other channel none provided

(please specify).
The reason the CVC was placed
through the 0.9 0.9 FALSE 100%
procedure note.
through the IV 0.8 0.8 FALSE 80%
assessment
flowsheet.
other channel none provided
(please specify).
What the CVC is currently being used for
through a patient 0.8 1.0 FALSE 80%
level summary
view (e.g., the
patient safety
dashboard).

through the IV 0.8 0.9 FALSE 90%

assessment
flowsheet.

==>

R2 R3 Relevance R4
Type & Channel Rationale Stability
I-CVI I-CVI changed Criteria
orally during 0.9 0.9 FALSE 80%
interprofessional
team rounds.
other channel none provided
(please specify).
a
signifies items to be included on the Round 4 Survey

Section III had the greatest number of unstable items. There were eight items that had

agreement less than 80%. There was also one item that was stable but changed relevance from

Round 2 to Round 3. In total, there were six items that changed relevance from Round 2 to 3.

(See Table 8 and Table 9). For factors that promote the use of the EHR for interprofessional

communication, one item, “same discipline,” was unstable and changed from not relevant to

relevant. Therefore, this item was marked for inclusion in the Round 4 survey.

==?

Table 8

 
&



 

R2 I- R3 I- Relevance R4
Promote Use of EHR Stability
CVI CVI changed Criteria
The number of years of experience 1.0 1.0 FALSE 100%
an individual has using an EHR.
The availability of summary views 1.0 1.0 FALSE 100%
such as dashboards or patient level
summary screens.
The ability to prompt or draw 1.0 1.0 FALSE 100%
attention to specific information,
such as ability to highlight an item
on a flowsheet.
The accessibility of the EHR so 1.0 1.0 FALSE 100%
that it can be viewed by anyone at
anytime.
A search feature that allows 1.0 1.0 FALSE 100%
clinicians to find specific
information.
The presence of a summary or 0.8 1.0 FALSE 80%
overview as found in narrative
notes.
An individual's comfort level with 1.0 1.0 FALSE 100%
technology.
The need to find specific details 0.9 0.9 FALSE 100%
and data about a patient.
I know the information might be 0.8 0.8 FALSE 80%
needed at a later date as a
reference.
I can more easily view trends. 1.0 0.9 FALSE 90%
I am more apt to use the EHR to 0.8 0.7 TRUE 70% 1, 3
share information with someone in
my discipline (nurse to nurse,
physician to physician). a
a
signifies items to be included on the Round 4 Survey

==@

For factors that inhibit the use of the EHR for interprofessional communication, eight

items were reviewed using the aforementioned criteria. Two of the eight items, although

unstable, demonstrated a clear consensus regarding relevancy and, therefore, were not marked

for inclusion in the Round 4 survey. Five items demonstrated a shift in relevancy and were

marked for inclusion in the Round 4 survey. One of these items “I don’t know the workflow of

other clinicians…” is unique in that 100% of the physicians rated this as relevant, yet only 50%

of the nurses rated this factor as relevant. This is the only item in the entire survey that resulted

in findings distinctive to the two different professional groups. However, by Round 4 this

distinction no longer existed. One final unstable item that did not result in a shift in relevancy

was also marked for inclusion in Round 4 because the I-CVI value was moving from not relevant

towards relevant. In summary, a total of six items in “factors that prohibit” were marked for

inclusion on the Round 4 survey.

Table 9

 
&



 

R2 I- R3 I- Relevance R4
Inhibit Use of EHR Stability
CVI CVI changed Criteria
It is too difficult to find the 0.8 1.0 FALSE 80%
information I am looking for.
The same information might be in 1.0 0.9 FALSE 90%
multiple places.
It is faster to 'go ask someone.’ 0.8 0.9 FALSE 90%
Lack of knowledge on how to use 0.8 0.9 FALSE 90%
EHR
I don't know the workflow of other 0.8 0.7 TRUE 70% 1, 3
clinicians and therefore don't know
where to look for certain types of
information. a
Information is not accurate due to 0.6 0.8 TRUE 60% 1, 3
'copy and paste' functionality. a

==A

R2 I- R3 I- Relevance R4
Inhibit Use of EHR Stability
CVI CVI changed Criteria
The relevant information is not in 0.7 0.9 TRUE 60% 1
the EHR. a
The EHR is not up-to-date. a 0.8 0.6 TRUE 60% 1
I can't have a discussion in the 0.5 0.7 FALSE 60% 2, 3
EHR.a
I can't confirm that information has 0.8 0.9 FALSE 70%
been received.
I can't highlight what is important. 0.6 0.4 FALSE 60%
I am working in close physical 0.9 0.9 FALSE 100%
proximity to other care team
members so we can have a
discussion instead.
I don't know the workflow of other 0.7 0.7 FALSE 100%
clinicians and therefore I am not
certain that other clinicians will be
able to view the information that I
documented.

It takes too many "clicks" to find the 0.7 0.8 TRUE 90% 1
information I am looking for. a
a
signifies items to be included on the Round 4 Survey
Summary and Implications for Round 4. A total of 10 items were identified as needing

further input from the panel based on the rationale provided above. There was one item in

Section I, two items in Section II, and seven items in Section III. For the Round 4 survey, only

these 10 items were included, thus resulting in a significantly shorter survey (See Appendix K.).

It was anticipated that a shorter survey would help prevent attrition. After the other items were

deleted from the Round 3 survey, the survey directions were updated to provide guidance for

completion of the Round 4 survey. Participants were informed that the items for consideration in

this round represented areas where consensus was not clear. Furthermore, they were reminded

that the group’s rating as measured by the I-CVI and additional comments were included under

each item. Also, as in Round 3, each panel member was provided with his or her own responses

==B

from the last survey round. Lastly, to encourage completion of Round 4, the e-mail that

contained the link to the survey emphasized that there were only 10 items requiring further

confirmation.

Summary of Round 4 Results

The Round 4 survey was sent out via e-mail approximately 4 weeks after the Round 3

survey. All 10 participants completed the survey within 4 weeks. This was the longest response

time for any of the survey rounds. Responses were once again analyzed in Excel to calculate the

I-CVI values and percent agreements for each item. Two of the final 10 items were unstable with

a percent agreement of 70%. (See Table 10). For one of the items, “not accurate,” the I-CVI went

from 0.8 to 0.9, indicating that there was no change in relevancy and instead a move towards

consensus regarding relevancy. For the second item, “not up to date,” the I-CVC went from 0.6

to 0.7, indicating a move towards consensus regarding relevancy; however, this still falls below

0.75 and is, therefore, deemed not relevant. There were three additional items that warranted

further consideration. First, the items “no discussion” and “same discipline” were stable;

however, the I-CVI moved from 0.7 to 0.9 indicating a change from not relevant to relevant.

Second, one item, “too many clicks,” was also stable but moved from relevant to not relevant.

Based on the criteria described to guide analysis in Round 3, the items “not up to date,” “no

discussion,” “same discipline,” and “too many clicks” may necessitate further input to draw a

conclusion regarding group consensus. It was decided to conclude with Round 4 due to

increasing response time (indicating panel fatigue) to mitigate possible attrition. All four of the

inconclusive items are from Section III, factors that promote or inhibit the use of the EHR for

interprofessional communication.

==C

Table 10

 
'
 

R3 R4
Relevance R4
Question Rationale I- I-
changed Stability
CVI CVI
Section I: Information Type
Reason the CVC was initially When deciding 0.7 0.8 TRUE 90%
placed whether or not to keep
the line, we look at the
present needs for the
line more than the
reason it was inserted.
Will help determine
need for it to remain in
place.
CVC are usually
placed for a handful of
reasons, poor access,
medication needs, etc.
I feel once these issues
are addressed or over,
the team usually is all
on board with whether
the CVC will be
continued or not.
If it was placed for
central access, which is
still required (drugs,
resuscitation), I
wouldn't want to
remove it.
Section II: Type & Channel
Number of intravenous medications that are being administered and whether they require
central administration would be most effectively communicated with the interprofessional
team

==D

R3 R4
Relevance R4
Question Rationale I- I-
changed Stability
CVI CVI
by flagging medications in It would be most 0.8 0.9 FALSE 90%
the medication effectively
administration record communicated via
(MAR) if they require communication, but
central administration. flagging medications
could assist with
communicating this
process when not
communicating
directly in inter
professional rounds,
etc.
Would be a good
reminder for newer
clinicians.
Save the nurse time
looking up the
medications and helps
to support the need for
the central line.
So the team knows
which meds need to be
given centrally to
support the use of the
CVC.
Agree, it is good for
the nurse, but not for
MDs.

==E

R3 R4
Relevance R4
Question Rationale I- I-
changed Stability
CVI CVI
by including the site of Helps understand 0.7 0.7 FALSE 80%
administration on the administration of
MAR for each medication meds. Concern for
(e.g., the time of last overload though.
administration of any IV Now, the
medication would include documentation is not
the port and site of always valid.
administration, such as, Nice to know but not
right, internal jugular, necessary.
proximal port or right To support which
forearm peripheral IV.) medication is given
and where.
Again, more useful for
nurse.
Section IIIa: Promote Use of EHR
I am more apt to use the EHR #N/A 0.7 0.9 TRUE 80%
to share information with
someone in my discipline
(nurse to nurse, physician to
physician).
Section IIIb: Inhibit Use of EHR
I don't know the workflow of #N/A 0.7 0.7 FALSE 80%
other clinicians and therefore
don't know where to look for
certain types of information.
Information is not accurate due #N/A 0.8 0.9 FALSE 70%
to 'copy and paste'
functionality.
The relevant information is not #N/A 0.9 0.9 FALSE 80%
in the EHR.
The EHR is not up-to-date. #N/A 0.6 0.7 FALSE 70%
I can't have a discussion in the #N/A 0.7 0.9 TRUE 80%
EHR.
It takes too many "clicks" to #N/A 0.8 0.6 TRUE 80%
find the information I am
looking for.

=><

Summary of Results for the Four Research Questions

There were four research questions posed to explore what an expert panel of nurses and

physicians believe regarding how the EHR ought to be used to optimize interprofessional

communication concerning CVC management and the prevention of CLABSI. The questions

were:

I. What type of information is best communicated asynchronously through

documentation in the EHR between nurses and physicians regarding the prevention of

CLABSI in patients with CVCs?

II. What type of information necessitates synchronous oral communication between

nurses and physicians regarding the prevention of CLABSI in patients with CVCs?

III. What are the factors that inhibit asynchronous communication through documentation

in the EHR between nurses and physicians regarding the prevention of CLABSI in

patients with CVCs?

IV. What are the factors that promote asynchronous communication through

documentation in the patient record between nurses and physicians regarding the

prevention of CLABSI in patients with CVCs?

Through the initial interviews and subsequent survey rounds, the panel determined what

information is needed to support decisions regarding CVCs. The panel then identified the best

channel for communicating each type of information, thus answering research questions I & II.

These results can be found in Section II of the Delphi surveys. Each of the communication

channels described in Section II can be labeled as an asynchronous or synchronous method. Out

of the 12 information types, there were four for which only an asynchronous method was

=>=

selected, two for which only a synchronous method was selected, and six for which both

synchronous and asynchronous methods were selected. (See Table 11).


=>>

Table 11





#
!
# $# 


R2 R3 R4 Channel
Type & Channel Rationale
I-CVI I-CVI I-CVI Type
Conditions under which the central venous line was placed
through the 0.9 0.9 n/a asynchronous
procedure note.
Difficulty getting peripheral venous access
through the EHR I am not 0.8 1.0 n/a asynchronous
in a familiar with
documentation such a
tool (e.g., in the documentation
IV assessment tool that has
flowsheet with such IV
fields that assessment
capture date of flowsheets that
last attempt to clearly
place peripheral document this
IV, number of clearly.
attempts by the
bedside nurse,
number of
attempts by the
IV nurse).

orally during best way 0.9 0.9 n/a synchronous

interprofessional during rounds
team rounds.
orally as soon as 1.0 1.0 n/a synchronous
it is noted.
Evidence of an infection
orally as soon as 1.0 1.0 n/a synchronous
there is a
concern.
orally during 0.9 0.9 n/a synchronous
interprofessional
team rounds.
The need for frequent blood draws

=>?

R2 R3 R4 Channel
Type & Channel Rationale
I-CVI I-CVI I-CVI Type
orally during 0.8 0.9 n/a synchronous
interprofessional
team rounds.
The functioning of the CVC
through the IV I am not 0.8 0.9 n/a asynchronous
assessment familiar with
flowsheet. which IV
assessment
flowsheet

orally during or even before 0.9 0.9 n/a synchronous

interprofessional rounds if the
team rounds. appropriate
providers are
available
The location of the CVC (subclavian, internal jugular, femoral)
through the IV 0.9 1.0 n/a asynchronous
assessment
flowsheet.
through a patient 1.0 1.0 n/a asynchronous
level summary
view (e.g., the
summary screen
that pulls data
from a procedure
note or IV
assessment
flowsheet).

orally during 0.9 0.8 n/a synchronous

interprofessional
team rounds.
Number of intravenous medications that are being administered and whether they require
central administration

=>@

R2 R3 R4 Channel
Type & Channel Rationale
I-CVI I-CVI I-CVI Type
by flagging 0.7 0.8 0.9 asynchronous
medications in
the medication
administration
record (MAR) if
they require
central
administration.

orally during 0.8 0.9 n/a synchronous

interprofessional
team rounds.
Number of days a CVC has been in place
through a patient 1.0 1.0 n/a asynchronous
level summary
view (e.g., the
summary screen
or patient
dashboard that
pulls data from
the IV
assessment
flowsheet or
procedure note).
The availability of other IV access
through the IV 0.8 0.9 n/a asynchronous
assessment
flowsheet.
through a patient 0.9 1.0 n/a asynchronous
level summary
view of all the
tubes, drains, and
airways.
The condition of the CVC site
through the IV 0.8 0.9 n/a asynchronous
assessment
flowsheet.
orally as soon as 1.0 1.0 n/a synchronous
a change is
noted.

=>A

R2 R3 R4 Channel
Type & Channel Rationale
I-CVI I-CVI I-CVI Type
The reason the CVC was placed
through the 0.9 0.9 n/a asynchronous
procedure note.
through the IV 0.8 0.8 n/a asynchronous
assessment
flowsheet.
What the CVC is currently being used for
through a patient 0.8 1.0 n/a asynchronous
level summary
view (e.g., the
patient safety
dashboard).

through the IV 0.8 0.9 n/a asynchronous

assessment
flowsheet.
orally during 0.9 0.9 n/a synchronous
interprofessional
team rounds.

Results from Section III of the survey address research questions III & IV. In this section,

findings indicated that there was consensus regarding 10 factors that promote the use of the EHR

for interprofessional communication and 11 factors that inhibit the use of the EHR for

interprofessional communication. (See Table 12 and Table 13).

Table 12


 











Promote Use of EHR R2 I-CVI R3 I-CVI R4 I-CVI

The number of years of experience an individual 1.0 1.0 n/a
has using an EHR.
The availability of summary views such as 1.0 1.0 n/a
dashboards or patient level summary screens.

=>B

Promote Use of EHR R2 I-CVI R3 I-CVI R4 I-CVI

The ability to prompt or draw attention to specific 1.0 1.0 n/a
information, such as ability to highlight an item on
a flowsheet.
The accessibility of the EHR so that it can be 1.0 1.0 n/a
viewed by anyone at anytime.
A search feature that allows clinicians to find 1.0 1.0 n/a
specific information.
The presence of a summary or overview as found in 0.8 1.0 n/a
narrative notes.
An individual's comfort level with technology. 1.0 1.0 n/a
The need to find specific details and data about a 0.9 0.9 n/a
patient.
I know the information might be needed at a later 0.8 0.8 n/a
date as a reference.
I can more easily view trends. 1.0 0.9 n/a
I am more apt to use the EHR to share information 0.8 0.7 0.9
with someone in my discipline (nurse to nurse,
physician to physician).

Table 13


 










Inhibit Use of EHR R2 I-CVI R3 I-CVI R4 I-CVI

It is too difficult to find the information I am 0.8 1.0 n/a
looking for.
The same information might be in multiple 1.0 0.9 n/a
places.
It is faster to 'go ask someone'. 0.8 0.9 n/a
Lack of knowledge on how to use EHR. 0.8 0.9 n/a
Information is not accurate due to 'copy and 0.6 0.8 0.9
paste' functionality.
The relevant information is not in the EHR. 0.7 0.9 0.9

=>C

Inhibit Use of EHR R2 I-CVI R3 I-CVI R4 I-CVI

I can't have a discussion in the EHR. 0.5 0.7 0.9
I can't confirm that information has been 0.8 0.9 n/a
received.
I can't highlight what is important. 0.6 0.4 n/a
I am working in close physical proximity to other 0.9 0.9 n/a
care team members so we can have a discussion
instead.

Conclusion

The objective of this study was to explore, via the Delphi technique, what nurses and

physicians believe regarding how the EHR ought to be used to optimize interprofessional

communication concerning CVC management and the prevention of CLABSI. The results of this

study first describe what types of information are necessary when making decisions regarding

whether to keep or discontinue a CVC. The expert panel of nurses and physicians identified 12

information types during the Round 1 interviews and, in the end, deemed all 12 items as relevant

to decisions regarding CVCs. The panel then arrived at consensus regarding which channels

were best suited for conveying each information type to the interprofessional team. For each

information type, there was at least one agreed upon method or channel for communication. In

some cases, more than one channel was selected for a particular information type. Each of these

channels represented a synchronous or asynchronous method. (See Table 11). Lastly, the panel

identified factors that promote or inhibit the use of the EHR for communication among the

interprofessional team, resulting in consensus regarding 21 factors. (See Table 12 and Table 13).

The aim was to achieve consensus regarding relevancy or agreement among the panel

members who represented two professional groups, nurses and physicians, to determine what

=>D

information is necessary for decisions regarding CVCs, how this information is best

communicated, and what factors promote or inhibit the use of the EHR for interprofessional

communication. The results from the four-round Delphi study presented here in chapter four

fulfill this aim.


=>E

Chapter 5: Discussion of the Findings

The purpose of this study was to describe, using the Delphi technique, what an expert

panel of nurses and physicians believe regarding use of the electronic health record (EHR) to

optimize interprofessional communication in central venous catheter (CVC) management and

prevention of central line–associated blood stream infections (CLABSI). One of the primary

long-term goals of this study is to provide guidance for the configuration of EHRs that more

effectively support interprofessional communication. The review of the literature demonstrated a

lack of research on how the EHR can be used to enhance communication between the nurse and

physician. However, previous research has revealed that nursing documentation communicates

nursing concern about patients and is predictive of patient outcomes (Chang et al., 1996; Collins

et al., 2013; Rothman et al., 2012), yet, nurses and physicians minimally use the patient record

when seeking patient information (Brown, Borowitz, & Novicoff, 2004; Coiera, Jayasuriya,

Hardy, Bannan, & Thorpe, 2002; Collins, Bakken, Vawdrey, Coiera, & Currie, 2011; Hripcsak,

Vawdrey, Fred, & Bostwick, 2011). The literature review also identified several factors that

inhibit the use of the EHR for communication and information sharing (Coiera, 1996; Collins et

al., 2011; Embi et al., 2013; Gilardi, Guglielmetti, & Pravettoni, 2014; Keenan, Yakel, Lopez, &

Tschannen, 2013; Kossman & Scheidenhelm, 2008; Rowlands & Callen, 2013; Street &

Blackford, 2001; Varpio, Schryer, & Lingard, 2009). However, a gap in knowledge exists

regarding best practices for how the EHR ought to be used to support interprofessional

communication. This study addresses this gap.

This chapter begins with a summary of the findings for each of the four research

questions and then presents a discussion of how the findings relate to the existing literature on

this topic. Next, the findings are considered in light of the theoretical frameworks that guided the

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study. Following this, the limitations of the study are discussed. Lastly, this chapter addresses the

implications of the findings for EHR development, practice, and education, and

recommendations for further research.

Summary of Findings and Discussion for Research Questions 1 and 2

The first two research questions were: (1) What type of information is best

communicated asynchronously through documentation in the EHR between nurses and

physicians regarding the prevention of CLABSI in patients with CVCs? and (2) What type of

information necessitates synchronous oral communication between nurses and physicians

regarding the prevention of CLABSI in patients with CVCs?.

Determining Information Types

Before exploring synchronous versus asynchronous communication channels related to

CVC management and the prevention of CLABSI, it was imperative to determine what types of

information the expert panel believed essential to this clinical work. The expert panel identified

12 information types:

1. Conditions under which the CVC was placed (e.g., emergently in the ED)

2. Difficulty getting peripheral venous access

3. Evidence of infection (e.g., fever, rising WBC)

4. Frequent blood draws

5. Functioning of the CVC (i.e., ability to flush and draw back blood)

6. Location of the CVC (e.g., IJ, SC, Femoral)

7. Number of intravenous medications being administered and whether they require

central administration

8. Number of days CVC has been in place


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9. Presence of other venous access

10.CVC insertion site condition

11.Reason the CVC was initially placed

12.What the CVC is currently being used for

These information types all represented indications or information to support decisions to keep

or discontinue a CVC.

There is a lack of research addressing what information is necessary to support decisions

regarding CVC management, despite calls for research in this area (Yokoe et al., 2014). Only

three prospective studies were found that described indications, either documented or reported by

clinicians, for the placement or continuation of a CVC (Cload, Day, & Ilan, 2010; Diaz, Kelly,

Smith, Malani, & Younger, 2012; Zingg et al., 2011). These three studies provide us with a

description of indications reported in practice; however, they do not provide expert consensus on

the validity or appropriateness of these indications.

In addition to these prospective observational studies, Chopra et al. (2015) surveyed a

multispecialty panel of experts to develop criteria for the use of peripheral inserted central

catheters (PICCs). Although the primary aim was to investigate the use of PICCs, they also

reported indications for non-tunneled CVCs among other intravenous catheters. This is the only

expert consensus found in the literature that included indications for CVCs. Findings by Chopra

and colleagues on CVC indications included continuous parenteral nutrition, unstable patients

requiring hemodynamic monitoring, multiple medications, large fluid infusions, administration

of blood or blood products, and the planned potential number of days the catheter would be in

place. This list differs from findings in the aforementioned studies and does not include one of

the most commonly reported indications, which is the lack of other viable access. Also surprising

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is the indication of administration of blood products because central venous access is not

required for administration of these supportive therapies. It is possible that these results are

inconsistent with the studies that looked at actual use because this study was focused on PICCs

and not non-tunneled CVCs. Therefore, the indications for non-tunneled CVCs perhaps were not

explored comprehensively.

Findings from the Delphi study presented here represent the expert consensus of nurses

and physicians from one healthcare system regarding the management of CVCs. Indications for

CVCs found in the literature review were used as probes, if needed, during the round one

interviews. However, before providing any probes, the researcher allowed the expert panel

members to offer their expertise and experience in determining necessary information types. As a

result, the findings from this study represent the consensus of expert clinicians who participated

on this panel. The information types identified in this Delphi study are in some cases consistent

with and in some cases in contrast to the available literature on indications for the placement or

continuation of a CVC. It is also important to note that for this Delphi study, the question posed

to the panel was what information was necessary for decisions “to keep or remove a CVC.” As a

result, a broader range of information types was provided by the expert panel. See Table 14 for a

comparison of indications across studies.


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Table 14

Comparison of Indications for CVCs

Chopra et al.,
Thate, 2017 Cload et Diaz, et al., Zingg et al.,
Authors 2015/ Moureau
(this study) al., 2010 2012 2011
et al., 2016
RAND/UCLA
Appropriateness
Delphi, expert
Study Type Prospective Observational Study method-
panel
multispecialty
panel
Conditions
under which
the CVC was
placed
Difficulty
Lack of
getting No peripheral
peripheral Routine
peripheral access
access vascular
venous access
access
Availability of
other access
Evidence of
Indication/information type

an infection
Need for
frequent blood
draws
Functioning
of the CVC
Location of
the CVC
Continuous
Number of Antimicrobial parenteral
intravenous therapy nutrition
medications
and whether Therapies Parenteral Multiple
they require nutrition medications
central Chemotherapy
administration
Inotropics
Number of Access needed
days CVC has for less than 14
been in place days

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Chopra et al.,
Thate, 2017 Cload et Diaz, et al., Zingg et al.,
Authors 2015/ Moureau
(this study) al., 2010 2012 2011
et al., 2016
Condition of
the CVC site
What the
CVC is
currently
being used for
Renal
replacement
therapy
Hemodynamic
Monitoring
monitoring
Cardiac
pacing
Large fluid
Resuscitation
infusions
Blood/blood
products

Determining the Best Channel: Asynchronous Versus Synchronous (Research Question #1

& #2)

After information types were identified by the expert panel, all 12 of these information

types were then further explored to determine what channel best supported the communication of

this information between nurses and physicians. To accomplish this, the 12 information types

were presented to the expert panel with a selection of possible ways for sharing the information.

All of the options or channels presented in the survey were derived directly from qualitative data

from the Round 1 interviews. For each information type, there were between one and four

possible options for communicating, and at least one option represented an asynchronous

channel for each of the information types. See Appendix I for the survey.

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Findings revealed that for all but two of the twelve information types, at least one

asynchronous channel was selected. The two information types that had no asynchronous

channel were “the need for frequent blood draws” and “evidence of an infection.” For these two

information types, clinicians demonstrated a preference for synchronous, oral communication.

However, for the remaining 10 information types, findings suggest that these expert clinicians

believe that the EHR, in almost all cases, is the best way to communicate specific information.

This is in contrast to the review of literature for this study that found that clinicians demonstrate

a preference for face-to-face or oral communication and use documentation minimally as a

means of communicating, particularly between members of different professional groups (Brown

et al., 2004; Coiera et al., 2002; Edwards et al., 2009; Hripcsak et al., 2011; Penoyer et al., 2014;

Törnvall & Wilhelmsson, 2008). It is possible that this difference is due to current clinicians’

exposure to and experience using EHRs, as the previous studies cited here are primarily more

than five years old. This difference could also be due to the way in which the topic was explored

in this study. The focus of this Delphi study was to identify best practices whereas other studies

noted here looked at actual or reported use of documentation for communication. Thus, although

past studies have demonstrated a clear preference for oral communication, findings from the

expert panel in this study indicate how the EHR ought to be used.

After further examination of the two information types in which no asynchronous channel

was selected, it was noted that both represent instances where one specific piece of information

may not adequately reflect the issue or concern. The need for frequent blood draws had an I-CVI

of 0.8, which means that eight out of ten panel members believed that this information was

necessary for decisions regarding whether to keep or discontinue a CVC. Additional free-text

comments from the panel members revealed that the need for frequent blood draws would not

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alone be a reason to keep a CVC and that other factors, such as why frequent blood draws are

needed, if frequent draws are still necessary, and whether there is another way to obtain blood

samples would need to be considered. The complexity of this particular issue may be the reason

why the expert panel selected a synchronous means of communicating.

Similar to frequent blood draws, evidence of an infection may require several pieces of

information to fully appreciate the issue. Although all 10 panel members (I-CVI = 1.0) rated this

information type as necessary for decisions regarding CVC management, they selected only

synchronous channels for communicating this information. Comments from panel members

revealed concern that individual pieces of information found in the EHR may not be viewed or

interpreted correctly and that oral communication could facilitate a more timely response or

intervention. This is consistent with a study by Gilardi et al. (2014) in which nurses created

workarounds to ensure that key pieces of information documented in the record were received

and understood. Although the panel members did not speak of specific workarounds, they

indicated that additional measures beyond reliance on documentation in the EHR should be taken

to ensure that the message was received and understood.

According to Coiera’s (1996) theory, clinicians demonstrate a preference for synchronous

channels for communication due to the “event-driven” nature of a particular issue, such as in the

case of evidence of an infection, and the complexity of a particular issue, as noted with both the

frequency of blood draws as well as evidence of an infection (p. 18). Although the panel clearly

demonstrated a preference for synchronous forms of communication with these two issues,

comments from the panel suggest that this information should also be included in the

documentation; however, they noted that it still requires oral discussion during interprofessional

rounds. This concern that orally communicated information also be documented so that it is not

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lost is consistent with previous research (Collins et al., 2011; Conn et al., 2009; Keenan et al.,

2013; Rowlands & Callen, 2013; Street & Blackford, 2001).

In summary, there was consensus among the panel that for all information types, except

frequent blood draws and evidence of an infection, there was an asynchronous channel best

suited for communicating the information. It was also clear that some asynchronous channels

were preferred over others. For example, for information related to the “conditions under which

the line was placed” and the “initial reason for placement,” the procedure note was selected as

the best means for communicating this information. This is in contrast to literature suggesting

that notes are used minimally (Brown et al., 2004; Hripcsak et al., 2011), but it is congruent with

previous research suggesting that physician notes, in particular, are viewed more commonly than

nursing notes (Hripcsak et al., 2011; Penoyer et al., 2014). For seven of the 12 information types,

a flowsheet was identified as the best channel for communication, consistent with previous

research. In Kossman et al.’s (2013) study examining EHR usage for nurses, physicians, and

other healthcare professionals, findings revealed that flowsheets were one of the most frequently

viewed EHR formats. Brown et al. (2004) surveyed physicians working in the neonatal intensive

care unit (NICU) and found that they also demonstrated a preference for the flowsheet. The other

most commonly identified format (in four out of the 12 information types) for communicating

information in this Delphi study was a patient level summary. This, too, is consistent with

previous research that demonstrated clinicians’ preference for summarized data (Brown et al.,

2004; Collins et al., 2011; Embi et al., 2013; Kossman et al., 2013). Qualitative data from Round

1 of this Delphi study also highlighted the usefulness of a specialized form, namely a safety

checklist, which was in use at this healthcare system. These qualitative data also align with

research that has demonstrated the usefulness of forms created to address specific

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communication needs (Agarwal et al., 2008; Phipps & Thomas, 2007; Pronovost et al., 2003). It

is important to note, however, that the studies listed here exploring the use of a specialized form

all focused on communication of daily goals and, therefore, cannot be generalized to the

usefulness of a safety checklist for team communication. Further research is needed to examine

this specific issue.

Lastly, it is critical to point out that for seven out of the 12 information types, both an

asynchronous and synchronous channel was selected to best communicate the information. These

findings corroborate previous research that stresses that even good documentation cannot take

the place of oral communication (Törnvall & Wilhelmsson, 2008) and, in turn, reliance on oral

communication alone may result in information loss (Collins et al., 2011; Conn et al., 2009;

Keenan et al., 2013; Rowlands & Callen, 2013; Street & Blackford, 2001). This leads to the

conclusion that the proper utilization of both synchronous and asynchronous channels is needed

to support effective communication among the interprofessional team. This study contributes to

this end by identifying the best combination of channels for each information type.

Summary of Findings and Discussion for Research Questions 3 and 4: Factors that

Promote or Inhibit the Use of the EHR

Research questions three and four respectively are: (1) What are the factors that inhibit

asynchronous communication through documentation in the EHR between nurses and physicians

regarding the prevention of CLABSI in patients with CVCs? and (2) What are the factors that

promote asynchronous communication through documentation in the EHR between nurses and

physicians regarding the prevention of CLABSI in patients with CVCs?.

The panel identified 11 factors that promote the use of the EHR for interprofessional

communication. The factors are listed here:


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1. The number of years of experience an individual has using an EHR.

2. The availability of summary views such as dashboards or patient level summary screens.

3. The ability to prompt or draw attention to specific information, such as ability to

highlight an item on a flowsheet.

4. The accessibility of the EHR so that it can be viewed by anyone at any time.

5. A search feature that allows clinicians to find specific information.

6. The presence of a summary or overview as found in narrative notes.

7. An individual's comfort level with technology.

8. The need to find specific details and data about a patient.

9. I know the information might be needed at a later date as a reference.

10.I can more easily view trends.

11.I am more apt to use the EHR to share information with someone in my discipline (nurse

to nurse, physician to physician).

Seven of the 11 factors had an I-CVI of 1.0, indicating that all 10 panel members agreed that

these factors promote the use of the EHR for communication. These seven factors can be

conceptualized by the following categories: user’s knowledge or skill, particular features of an

EHR, and the general accessibility of the electronic record. In the review of the literature, the

availability or accessibility of the record was the primary factor cited as promoting the use of

documentation (Embi et al., 2013; Kossman & Scheidenhelm, 2008; Rowlands & Callen, 2013),

whereas user’s knowledge or skill and particular features of an EHR were not found in the

literature.

Previous research also showed some indication that team cohesion or the extent of the

relationship between clinicians may impact information sharing through the EHR. Findings from

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this Delphi study align with this as illustrated in the statement, “I am more apt to use the EHR to

share information with someone in my discipline (nurse to nurse, physician to physician).”

Additionally, team cohesion or the relationship between clinicians reflects the concept of

common ground as described by Coiera, meaning that when there is an existing relationship and

shared experiences between clinicians this common ground positively influences information

sharing through asynchronous modes such as the EHR.

Although there were some commonalties between the findings from the present study and

previous research, this study identified several additional factors that promote the use of the EHR

that were not reported in the literature. This provides more insight into how to encourage EHR

use because it promotes interprofessional communication. It is not clear whether the factors or

features identified in this Delphi study exist in the panel members’ current EHRs or if these are

desired features; nonetheless, these factors should be considered when designing EHRs, when

implementing an EHR in a health system, or when configuring EHRs for a particular group or

setting.

The panel also identified 10 factors that inhibit the use of the EHR for interprofessional

communication and, ultimately, agreed upon eight inhibiting factors, all with an I-CVI of 0.8 or

above. The first three factors, “it is too difficult to find information I am looking for,” “the same

information might be in multiple places,” and “it is faster to go ask someone,” all address

challenges in efficiently finding the needed information documented by another clinician. These

data are in agreement with previous research in which clinicians reported and perceived

difficulty finding information in the record (Collins et al., 2011; Embi et al., 2013; Kossman &

Scheidenhelm, 2008). Other inhibiting factors from this study that are consistent with previous

literature include:

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1) “I can’t confirm that information has been received” (Coiera, 1996; Embi et al., 2013;

Gilardi et al., 2014; Varpio et al., 2009);

2) “relevant information not in the EHR,” which is similar to previous research reporting

that an inhibiting factor was documentation that did not consistently include goals of care

(Collins et al., 2011; Embi et al., 2013) and lacked details regarding oral exchanges

(Collins et al., 2011; Keenan et al., 2013; Rowlands & Callen, 2013);

3) and “information is not accurate due to copy and paste functionality”, which reflects

previous findings that identified the low quality of documentation as an inhibiting factor

(Embi et al., 2013; Rowlands & Callen, 2013; Street & Blackford, 2001). The concern

regarding the low quality of documentation from previous studies may also be captured

by the statement, “relevant information not in the EHR.”

In contrast, “lack of knowledge on how to use the EHR” and “I am working in close

proximity to other care team members so we can have a discussion instead” were identified as

factors that inhibit the use of the EHR for interprofessional communication and were not

reported in previous research.

Additionally, the expert panel members in this study did not believe that the problem of

“the EHR is not up to date” was an inhibiting factor as previous studies reported (Collins et al.,

2011; Embi et al., 2013). Lastly, two factors that inhibit the use of the EHR described in previous

studies but not identified by this expert panel included the perception that notes are not read and

the lack of a patient overview or summary, thus suggesting that these are not perceived as issues

by this particular expert panel. This study adds to the existing body of literature on factors that

promote or inhibit the use of the EHR for interprofessional communication.


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Findings and the Theoretical Frameworks

The theoretical frameworks of distributed cognition and Coiera’s communication space

guided the development of the research questions for this study and provided structure for the

coding framework used to develop the surveys in rounds two through four. As such, specific

findings from this study represent the application of the theories’ concepts and propositions to a

specific clinical issue, CVC management, and the prevention of CLABSI. Study findings support

the concepts described in the two theoretical frameworks and, in some cases, extend or add to the

theories described previously.

First, results from this study further explicate the representational states that support the

communication of information pertaining to CVC management and the prevention of CLABSI.

The focus of this study was on the use of the EHR for information sharing, and the expert panel

members described and then reached consensus regarding the optimal representational states for

communicating each information type. Furthermore, findings are congruent with the relationship

posited between common ground and the use of asynchronous channels in Coiera’s framework.

The expert panel identified and confirmed that membership in the same professional group,

which is reflective of common ground, promoted the use of the EHR an asynchronous channel

for information sharing.

Second, results from this study affirm that the concept of common ground as described

by Coiera should include common ground with the artifact facilitating information sharing.

Coiera discusses the idea that grounding may occur between an individual and an informatics

tool (Coiera, 2003); however, he defines common ground as “knowledge shared by two

communicating agents” (Coiera, 2000, p. 282). Results from this study, included in the section,

“factors that promote the use of the EHR for information sharing,” indicate that factors related to

=@?

an individual’s experience with or competency using a particular artifact, such as an EHR, may

promote its use. Thus, extending the definition of common ground to more explicitly include not

only the relationship between the two human actors, but also the relationship between a human

actor and an artifact, is important. Interestingly, as noted previously in this chapter, in most

cases, expert panel members selected an asynchronous channel for information sharing. This is

in contrast to previous research and may be attributed to increased common ground with

technology in the current generation of clinicians.

Third, after analysis of results from this study, it is proposed that an additional concept be

considered in both frameworks. Section one of the Delphi survey elicited panel members’ insight

into what information type is necessary for decisions regarding CVC management. Neither

framework specifically includes a concept regarding the implications of the information type on

communication practices. In regards to information specifically, distributed cognition focuses on

representational states—the structures that convey the information. Similarly, Coiera’s

communication space focuses on the exchange of information including the channel type—

synchronous or asynchronous—and the influence of common ground. To explore the concepts of

representational states, synchronous versus asynchronous channels, and common ground, this

study began by reaching consensus regarding what information type is needed to make decisions

regarding the management of CVCs. The information type is an important distinction when

considering what type of channel or what type of representational state is most effective. As

noted in the study findings, the panel selected a synchronous channel for two information

types—the need for frequent blood draws and evidence of infection. The investigator purports

that this preference for synchronous communication may be due to the complexity of the

=@@

information or the need for prompt response or action which has also been noted by Coiera

(1996).

The complexity of the information being communicated may also lessen the contribution

of common ground. Findings from this study suggest that complexity inversely influences

preferences for asynchronous channels and, therefore, may impact the strength of the relationship

between common ground and channel selection. See Figure 3. For example, in spite of common

ground between two clinicians, due to membership in the same professional group or experience

working together, when an issue is complex, ambiguous, or requires several pieces of disparate

data to make a clinical judgement, clinicians with high levels of common ground may still

demonstrate a bias for synchronous communication.





















Figure 3. Impact of Complexity on Channel Selection as Compared to Common Ground


=@A

The complexity of the information being communicated also influences the

representational state used. For example, for information regarding the availability of other IV

access, the expert panel in this study agreed that the IV flowsheet or a patient level summary

would be the most effective means for information sharing. However, for information regarding

conditions for which the CVC was placed—a more complex issue—the panel agreed that this

would be best communicated through the procedure note, which allows for more detailed

explanation. These examples illustrate the importance of considering complexity and information

type as concepts to be incorporated in the theoretical frameworks.

Lastly, in addition to supporting and extending the theoretical frameworks, the

methodological approach of this study, which seeks to reach a negotiated reality among panel

participants, uniquely complements both frameworks. The intention of distributed cognition is to

reach a shared understanding, and Coiera’s communication space emphasizes the influence of

common ground on the selection of communication channels. The Delphi technique is structured

with the aim of reaching group consensus or opinion; as such, in this study, it contributed to the

attainment of common ground and a shared understanding regarding what artifacts support

interprofessional communication and preferred communication channels. This approach resulted

in suggested best practices rather than just a description of communication in its natural state.

Additionally, the methodological approach aimed to establish common ground between nurses

and physicians on how to communicate specific pieces of information with the hope of

facilitating more effective asynchronous exchanges. Rather than determining where on the

information continuum a particular information task should take place, common ground was

developed to move a communication task towards an asynchronous channel. As Coiera notes,

preemptive grounding comes at a cost in terms of time and effort (Coiera, 2003). However, the

=@B

use of the Delphi method provides a means to understand how informatics tools can best support

communication, and although it comes at a cost of time and effort, the method fits with Coiera’s

philosophy that informatics tools should conform to meet the needs of clinicians (Coiera, 2000,

2015).

Limitations of the Study

A Delphi study is similar to qualitative and survey-based research in that it relies on

participants’ ability to articulate their point of view and share their expertise. Although this may

be viewed as a limitation in other study types, this is one of the key strengths of this study that

sought to obtain expert opinion to determine best practices. Delphi studies in particular are

further strengthened by methods used to seek consensus or agreement among panel participants

through multiple rounds.

A Delphi study is dependent on the selection of panel members who are experts regarding

the issue under investigation. Therefore, the composition of the expert panel can be a potential

limitation of the study (Keeney, Hasson, & McKenna, 2011). For this study, panel members

were selected based on criteria related to practice experience, care of patients with CVCs,

knowledge regarding CVC management and the prevention of CLABSI, and experience using an

EHR. Participants verified that they met panel criteria when completing the initial consent and

demographic survey. Sampling was purposive and relevant to the concepts being explored. The

aim was to ensure that the sample was representative of clinicians from various roles within the

professions of nursing and medicine; however, there was a lack of IV therapy nurses on the

expert panel. Several efforts were made to recruit nurses from the IV therapy team, including the

use of key informants and snowball sampling, yet these attempts were unsuccessful. Future work

should attempt to capture input from this group of clinicians. A description of the expert panel

=@C

member characteristics is included in Chapter Four to allow the reader to draw informed

conclusions regarding how the results may apply to another context.

The initial aim for this study was to obtain a panel of 12 to 18 participants. Thus, if there

was any attrition, the final panel size would remain above the minimum of 10 needed to satisfy

the guidelines set forth by Polit, Beck, and Owen (2007) for calculating I-CVI values consistent

with percent agreement scores comparable to a modified kappa rating of excellent. Although the

panel for this study ultimately consisted of 10 clinicians—four physicians and six nurses with no

attrition—the panel size remained at a total of 10 for the entire study. As noted in the section on

recommendations for further research, confirming the results from this study with a larger group

is recommended.

This study was conducted with clinicians from a single healthcare system that included

three separate institutions—a large academic medical center and two community teaching

hospitals. Use of a single healthcare system may be viewed as a limitation, but the use of three

different sites within the system strengthens this study. Although an EHR from one vendor was

used by all sites, there were variations in local design and implementation of the EHR in each

setting. Throughout the study, participants were guided to remain system agnostic and think of

the ideal state as they considered best channels for sharing information and possible factors that

promote or inhibit the use of the EHR. This perspective is illustrated in participant comments

such as “I am not familiar with such a documentation tool” when describing a channel to convey

a particular information type, thus demonstrating that their responses or suggested channels were

not limited to what was currently available.

Lastly, the selection of the Delphi method as opposed to a focus group is important to

consider. Although focus groups may facilitate discussion and perhaps draw out additional

=@D

information, a Delphi study, where the participants are anonymous to one another, helps to

minimize the impact of power differentials or dominant points of view. Therefore, this method

allows for balanced input from all participants, which is key when seeking agreement from

participants who are members of different professional groups.

Implications of the Findings for the Development of EHRs

Although advances in health information technology have the potential to make care

safer, implementation and design decisions of EHRs could impede information sharing of critical

information (IOM, Committee on Patient Safety and Health Information Technology, 2012). The

Institute of Medicine (IOM) stressed the importance of a collaborative, interdisciplinary

approach to the development of information systems because different groups tend to use

systems differently, which may negatively impact collaborative work. Studies exploring

clinicians’ perceptions regarding the EHR have found that clinicians do not believe that the

current design and use of EHRs support interprofessional collaboration (Bardach et al., 2017;

Embi et al., 2013; Keenan et al., 2013).

The study presented here is unique in that it aimed to develop consensus among nurses

and physicians regarding best practices to support communication related to CVC management

to address a particular adverse outcome—the prevention of CLABSI. One of the key strengths of

this study and the use of the Delphi technique is the attainment of agreement between the two

professional groups represented on the expert panel. Findings address issues associated with

discipline specific practices or workflows that may hinder effective information sharing. In

addition, findings from this study can be used to guide the development of EHRs that support

interprofessional communication related to CLABSI prevention. The first step towards this goal

=@E

is ensuring that the information identified by this expert panel as relevant to CVC management is

a part of the EHR and is available via the channels designated by this expert panel.

Eleven of the twelve information types identified to support decisions on whether to keep

or discontinue a CVC reached agreement and were deemed necessary for these decisions.

Qualitative data from the Round 1 interviews and in comments provided during the survey

rounds suggest that in the participants’ practice settings, all of the information types identified

are currently captured in routine documentation, albeit in various places or formats in the EHR,

except for information related to difficulty obtaining peripheral IV access. It is critical that

information regarding the assessment for potential peripheral access and attempts to obtain this

access be available to the care team when making decisions regarding the continuation of a CVC.

Initial interviews with the expert panel suggested that this information is documented unreliably.

Interviews in this present study as well as previous research on documentation related to CVC

management (Thate et al., 2016) revealed that this information is (1) known by the IV therapy

nurse who manages efforts to obtain alternative access, (2) commonly documented in a form that

exists outside the EHR, and (3) communicated orally to the bedside nurse. As a result, this

information may not be reliably communicated to the entire team. Our findings suggest that this

information be included in routine documentation alongside other data on the IV assessment

flowsheet. In light of the other information types identified in this study, efforts should focus on

ensuring that this information is readily available when making decisions regarding CVC

management, which may require inclusion of this information or links to this information, on a

tool such as a safety checklist.

In addition to information types, preferred channels for communicating information were

identified and agreed upon by this expert panel. Nursing leaders, physician leaders,

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informaticians, EHR vendors, and those responsible for design choices and implementation

processes for EHRs should use these findings to ensure that the selected channels are available

and that duplicate, non-preferred channels are removed or no longer used. One of the major

challenges with EHR design, implementation, and use is the customization of EHRs to

accommodate preferences of individuals, professional groups, and local institutions. Although

customization is highly desirable and arguably supports practice needs and workflows to enable

EHRs to help—rather than hinder—the delivery of care (Feufel, Robinson, & Shalin, 2011), in

some cases, customization may negatively impact the provision of safe care if critical, relevant

information is not documented or viewed. In cases where there are evidence-based rationales for

particular EHR structures, as described in findings from this study, nurse and physician leaders,

as well as, administrators and EHR vendors, should discourage local customization that is

counter to the evidence.

Through the present study, several factors that promote or inhibit the use of the EHR for

interprofessional communication were identified. These factors confirm and expand existing

research on how the EHR facilitates collaborative work. Nurse and physician leaders,

informaticians, and EHR vendors may use these factors to inform EHR design, implementation,

and use. Several of the factors identified focus on existing or potential EHR features or

functions, such as a search feature or the ability to highlight important information for another

clinician. Where feasible, these features or functions should be employed.

Implications of Findings for Interprofessional Practice

In addition to designing and configuring EHRs that better support interprofessional

communication, we must also provide guidance for clinicians regarding best practices for

documenting and communicating key information to the team. Findings from this study have

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implications for the development of documentation policies. Standardization regarding what,

where, and how to optimally document can support interprofessional communication by ensuring

that information is available to other team members where, how, and when it is needed (Feufel et

al., 2011; Finn, 2015). Such practices have the potential to decrease adverse events that result

from failures in communication.

These findings also provide guidance for when other forms of communication, such as

synchronous oral exchanges, are necessary. Clinicians must be aware of the interdependent

nature of written and oral communication, and must recognize that in many cases, both a

synchronous and asynchronous method is needed. The literature indicates that one of the

drawbacks of EHRs on collaboration is the resultant decrease in oral, synchronous

communication because clinicians no longer need to be in the same physical location to view the

patient record (Bardach et al., 2017; Embi et al., 2013). The literature also suggests that even the

best documentation cannot completely replace oral communication (Edwards et al., 2009;

Rowlands & Callen, 2013; Törnvall & Wilhelmsson, 2008). In fact, overreliance on

documentation in EHRs for communicating is problematic, and clinicians commonly employ

such measures as following up via phone or using a sticky note to draw attention to particular

data as a way to ensure that critical information is relayed to the appropriate team member (Conn

et al., 2009; Gilardi et al., 2014; IOM Committee on Patient Safety and Health Information

Technology., 2012).

Findings from this study clearly support the use of both synchronous and asynchronous

channels: in almost all cases, both channel modalities were selected for each information type.

These results can be used to provide pragmatic guidance to clinicians regarding effective

communication practices. Institutional policies regarding documentation and communication are


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critically important because communication failures are one of the greatest contributors to

adverse events (The Joint Commission, 2016).

Of note, the most commonly selected synchronous channel in this study was

interprofessional team rounds. The use of this channel should be considered in light of research

on the under-represented view of the nurse during interprofessional rounds (Rowlands & Callen,

2013; Weber et al., 2007; Zwarenstein et al., 2013). Also, qualitative data from panel members in

this study who practice outside the ICU suggest that interprofessional rounds regularly don't

include the bedside nurse, thus limiting the effectiveness of this communication channel.

However, our results demonstrated agreement among panel members that interprofessional team

rounds was one of the best channels for seven of the eleven information types. This again speaks

to the potential utility of a checklist during rounds that includes links to the documented

information identified in this study, thus ensuring that information from the nursing perspective

is included in discussions.

Lastly, it is evident in the literature related to CLABSI prevention that greater emphasis

should be placed on post-insertion issues such as the removal of unnecessary CVCs (Burdeu et

al., 2014; Chopra et al., 2014; McLaws & Berry, 2015; McNamara et al., 2011; Render et al.,

2011; Richardson & Tjoelker, 2012; Zingg et al., 2014). As noted previously, Yokoe et al.

(2014) suggested that acute care organizations provide a list of evidence-based indications for

CVCs to promote removal of non-essential lines. Results from this study contribute to the

development of these evidence-based indications and can be used to develop policies aimed at

ensuring the necessary information is available to the team to support the removal of non-

essential lines.

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Implications of Findings for Interprofessional Education

Study findings may also be used to create interprofessional educational offerings

regarding documentation practices that support team collaboration and communication. For

example, nursing and interprofessional educators should highlight what documentation practices,

such as those revealed in this study, best support interprofessional work, including when to use

synchronous versus asynchronous channels. Study findings specific to documentation practices

related to CVC management could be included when curricular content focuses on the use of

vascular access devices and the related skills. Lastly, just as this study sought agreement from

nurses and physicians regarding best practices for communication through the EHR,

interprofessional educational experiences that include an exploration of the documentation

preferences and practices of different professional groups may lessen siloed, single discipline

documentation practices that impede collaboration through the EHR.

Recommendations for Further Research

Results from this study should be confirmed with a larger panel of experts from various

clinical settings. While this study began with individual interviews and analysis of qualitative

data, which is labor intensive, and therefore, may limit the panel size, a follow-up Delphi study

that starts with survey rounds based on the findings from this study would make a larger scale

study more feasible. Using the list of information types and channels identified in this study, a

computer mediated Delphi study would facilitate capturing insight from a geographically

dispersed panel. Also, as noted previously, future studies to confirm these findings should

include nurses who practice as part of the IV therapy team.

Additionally, this study could be replicated and extended to explore how the EHR should

be used for interprofessional communication about other significant clinical issues, such as

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patient falls, delay in treatment, post-operative complications, and medication errors. It has been

well documented that communication failures are key contributors to adverse events in

healthcare (James, 2013; The Joint Commission, 2016). Another key component of improved

communication to prevent harm involves seeking input from patients and families. Emerging

literature has emphasized that the patient should be viewed as the central member of the

healthcare team. In support of this, as patient records evolve to include information documented

by patients themselves, future research should also consider the incorporation of patient-entered

data when seeking to understand how documentation in the EHR supports information sharing,

improves interprofessional communication, and prevents harm.

Due to the paucity of research on specific indications for the placement or continuation of

a CVC, further research using the Delphi technique is warranted to focus specifically on best

practices for indications for CVCs. Results from such a study could help to lessen the use of non-

essential catheters and, in turn, prevent CLABSI. This research could include experts in infection

control as well as practicing clinicians.

Further research should also include efforts to examine how the impact of the

communication practices identified in this study contribute to a reduction in CLABSI. Findings

from the present study could be used to configure the EHR in such a way that it includes the

identified information types and corresponding communication channels. A pre-post intervention

study could be conducted where number of catheter days and CLABSI rates are measured before

and after implementing changes in the EHR. Similarly, the use of checklists—a specific tool

designed to support communication—should be evaluated to better understand its impact on

improving interprofessional communication.


=AA

Conclusion

To achieve “a symbiotic relationship between human cognition and computer support,” a

collaborative interprofessional approach is needed to design and implement EHRs that support

safe care (Institute of Medicine (IOM), 2012, p. ix). This study is unique in that it aimed to

develop consensus among nurses and physicians to identify best practices for communication

related to CVC management to address a particular adverse outcome—the prevention of

CLABSI. This study addressed a gap in the literature by moving beyond a description of current

practices or perceptions regarding how the EHR supports collaboration and interprofessional

communication to a description of how the EHR ought to be used based on expert opinion.

Guided by the frameworks of distributed cognition and Coiera’s communication space,

this Delphi study identified information necessary for decisions regarding CVC management and

the prevention of CLABSI, the best channels for communicating this information, and factors

that promote or inhibit the use of the EHR for interprofessional communication. These findings

are clinically meaningful and should be used to guide interprofessional practice, interprofessional

education, and the development of EHRs that better support interprofessional communication

and team-based care. Understanding how to optimize the EHR to leverage the knowledge

captured in clinicians’ documentation has the potential to improve patient care and reduce harm.

Key directions for future research include exploring best practices for documenting and

communicating information pertinent to other clinical issues so that the EHR can fulfill one of its

most critical aims—supporting interprofessional collaboration. As healthcare continues to evolve

and change, future work examining information sharing through the EHR will need to also

include the implications of patient-entered data. In a highly specialized and fragmented


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healthcare environment, communication is the linchpin for effective, safe care. The EHR must

facilitate good communication not hinder it.


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=CB

Appendix A

Expert Panel Criteria

Inclusion criteria for practicing nurses and physicians

• A minimum of 2 years' experience in practice setting
• Works an average of 24 to 36 hours per week at minimum
• Experience caring for patients with central venous catheters
• Knowledge regarding CVC management and the prevention of CLABSI
• Experience working with an EHR

Panel composition: target total 12-18 participants

Nurses:
• 3 practicing bedside nurses
• 1 intravenous therapy nurse
• 1 nurse leader (e.g., charge nurse,
nurse manager or director)
• 1-4 additional from any of the
above categories
Physicians:
• 3 residents or hospitalists
• 1 infection control physician
• 1 physician leader (attending,
medical director)
• 1-4 additional from any of the
above categories

=CC

Appendix B

Participation Request Letter

Dear____________________,

Healthcare-related harm is now estimated to be the 3rd leading cause of death in the U.S., and
poor communication has been identified as a key contributing factor in approximately 70% of
sentinel events. Documentation is intended to support communication and interprofessional
collaboration, yet research has demonstrated that documentation in the electronic health record
(EHR) is not regularly used.

As a part of my doctoral studies at Villanova University, I am conducting a Delphi study to

explore what nurses and physicians believe regarding how the EHR should be used to support
interprofessional communication. For this study, preventing central line associated blood stream
infections (CLABSI) in patients with central venous catheters (CVC) has been selected as a
model case. The results will be used to suggest best practices or guiding principles regarding
how the EHR ought to be used for interprofessional communication concerning the management
of CVCs and the prevention of CLABSI.

We believe that you have expertise that would significantly contribute to this study and that you
meet the inclusion criteria for the expert panel. The inclusion criteria for your professional group
include:

• A minimum of 2 years of experience working in an acute care setting averaging 24-36

hours per week
• Experience caring for patients with CVCs
• Experience working with an EHR
• Knowledge regarding CVC management and the prevention of CLABSI

If you do in fact meet these criteria and are willing to participate please use the following link to
indicate your interest by {insert DATE-reflects one week after recruitment letter sent}. This link
also includes information regarding informed consent and a survey eliciting demographic data.

{Partners REDCap LINK}

The Delphi technique being used for this study typically consists of three to four rounds. Round
one will consist of an in-person or online interview that will take approximately 60-90 minutes.
Every round there after will consist of a survey sent to you as a link via email. These surveys
should take approximately 30 minutes to complete.

Interviews will be scheduled at your convenience during the month of {September}. Round two
surveys will be sent out the beginning of {November}, and Round three surveys the beginning of
{December}. The total time commitment over the course of the study will be approximately 3

=CD

hours. We recognize that this represents a significant commitment on your part, but it is
important that you participate in all rounds. A summary of the results will be provided to you at
the conclusion of the study.

Please note that your participation in this study is completely voluntary. There will be no penalty
or consequence if you chose not to participate. All information you provide will be kept
confidential. The reporting of study results will not include any information regarding your
identity. All responses will be labeled with a unique code that is only identifiable by the
researchers. You will also remain anonymous to other members of the panel.

Thank you for considering taking part in this study. If you have any questions regarding the
study or your participation, you can contact the Primary Investigator, Sarah Collins, by email
sacollins@partners.org or by phone 781-416-9287 or Jenna Thate (doctoral student)
jthate@partners.org or 518-812-6233.

Kind Regards,

Sarah Collins, RN, PhD

Jennifer (Jenna) Thate RN, MSN, PhD candidate


=CE

Appendix C

Informed Consent

  
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Appendix D

Interview Guide

Introductory statement:
In the context of CVC management and the prevention of CLABSI, think of the ideal
state regarding what information needs to be communicated between nurses and
physicians. Consider what information would help shorten the length of time a CVC
remains in place, or what information might prevent the placement of unnecessary CVCs.
Next think about the best way to communicate this information. Although
communicating face-to-face is usually less time consuming, this type of communication
can be a source of interruption contributing to errors. Also, when information is only
shared through conversation, these details are then “lost” and not reliably available to
other team members.
So, think about when it would be appropriate to communicate via your documentation in
the EHR. As you think about using the EHR to communicate, don’t be limited by what
you think the EHR is capable of; instead consider how you use your phone or tablet, or
how particular apps make a task easier.

Questions for Round One Supporting Rationale

1) What information is necessary to support Provides common ground for the

decisions regarding whether to continue or questions that follow.
discontinue a CVC? Addresses aspect of research question
• Probes based on preliminary study at (RQ)1 & 2.
BWH (Thate et al., 2016) and literature
on CLABSI prevention

2) Where is this information found? Elicits information regarding

• In the patient record? artifacts used to store information or
• In another form of documentation? representational states within the
• Within an individual clinician (i.e., the activity system.
nurse, the medical resident)? Addresses aspect of RQ 1 & 2.

3) How is this information communicated among Elicits information regarding

the interprofessional team? artifacts used to store information
• It is discussed during interprofessional and rules or norms that guide
rounds behaviors.
• It is a part of the CLABSI Addresses aspect of RQ 1 & 2.
bundle/checklist
• If there is an issue, I go and find someone
• It is something that the IV therapy nurse
would know (information rests within an
individual)

=D>

• It is documented on the flow sheet

• It is in my progress note
4) Of the information necessary to support Elicits information regarding rules or
decisions regarding whether to continue or norms that guide behaviors and
discontinue a CVC, what should be shared via reliance on artifacts.
the EHR? Addresses RQ 1.

5) Of the information necessary to support Elicits information regarding rules or

decisions regarding whether to continue or norms that guide behaviors.
discontinue a CVC what information necessitates Addresses RQ 2.
a synchronous exchange (i.e., impromptu to oral
discussion, phone call, interprofessional rounds)?

6) What are the factors that inhibit the sharing of Elicits rules or norms that guide
information via the EHR? interactions within the activity
• Factors identified in the literature review system.
will be used as probes. Addresses RQ 3.

7) What are the factors that promote the sharing Elicits rules or norms that guide
of information via the EHR? interactions within the activity
• Factors identified in the literature review system.
will be used as probes. Addresses RQ 4.

8) Has anything been missed or is there anything Allows participants to provide

else you would like to add? additional information that may not
have been elicited by the interview
questions.

Interviews will be recorded and transcribed. In addition grids will be used to take notes during
interviews.
Description of Where information How is this information How should this
Information is found shared/communicated information be
shared/communicated

Factors that inhibit the use of the EHR for Factors that promote the use of the EHR
Communication: for Communication:

=D?

Appendix E

Description of Rounds

Round One
• Conduct in-person or online semi-structured interviews (see interview guide).
• Audio record and transcribe interviews.
• Qualitative content analysis to generate list of:
1) Type of information and where this information is found
2) Channel for sharing information for each type of information identified
3) Factors that promote or inhibit communicating via the EHR

Round Two
Section I: Relevance of type of information.
• Provide a comprehensive list of the “information needed” as identified by the panel.
• Have the panel members rate each item according to its relevance.

Example:
Not Somewhat Quite Highly
Type of information Relevant Relevant Relevant Relevant
1 2 3 4
Number of antibiotics the patient is
receiving

IV nurses assessment of potential for

peripheral access

Space to add type of information:

(Expert can free text response)

Section II: Agreement regarding appropriate channel.

Example:
Disagree Somewhat Somewhat Agree Rationale
Type of information & channel disagree agree
1 2 3 4

Asynchronous channels
Number of antibiotics the patient is
receiving should be communicated
via the Medication Administration
Record in the EHR

IV nurse’s assessment of potential

for peripheral access should be

=D@

communicated via a nursing note in

the EHR

Synchronous channels

Both
Patient is febrile should be
communicated via the flowsheet in
the EHR and synchronously either
in-person or by phone

Space to add type of information &

channel:

Section III: Relevancy of factors that promote or inhibit communication via the EHR.

Not Somewhat Quite Highly

Factors that promote communication via Relevant Relevant Relevant Relevant
EHR 1 2 3 4
The person I am communicating with is a
member of my professional group

I rarely am working in the same physical

space as the rest of the team

Space to add factor:

Not Somewhat Quite Highly

Factors that inhibit communication via Relevant Relevant Relevant Relevant
EHR 1 2 3 4
It is too hard to find the information I am
looking for

I have no confirmation that my note has

been read (or the information was received)

Space to add factor:

Round Three
Section I: Relevance of information.
Resend list with I-CVI next to each item, along with the individual panelists rating. For all items
that did not achieve an I-CVI of 0.75*, list as items to be dropped. Panelists will have the

=DA

opportunity to re-rate each item (including items to be dropped) by either filling in the same
rating as in round two or by adjusting their rating.

Section II: Agreement regarding appropriate channel.

Resend list with I-CVI next to each item, along with the individual panelists rating. For all items
that did not achieve an I-CVI of 0.75*, list as items that indicate disagreement. Panelists will
have the opportunity to re-rate each item (including both items which demonstrate agreement
and those that indicate disagreement) by either filling in the same rating as in round two or by
adjusting their rating.

Section III: Factors that promote or inhibit communication via EHR.

Resend list for both factors that promote and inhibit communication via the EHR with I-CVI
next to each item, along with the individual panelists rating. For all items that did not achieve an
I-CVI of 0.75*, list as items to be dropped. Panelists will have the opportunity to re-rate each
item (including items that will be dropped) by either filling in the same rating as in round two or
by adjusting their rating.

*An I-CVI of 0.75 for a panel of 10 or more is equivalent to “excellent” rating when computing
kappa for agreement on relevance. If the panel is less than 10, the I-CVI cutoff will be increased
to 0.78 (Polit , Beck, & Owen, 2007).

Round Four
• If stability of responses has not been achieved, repeat as described in round three.
• If stability of responses has been achieved, prepare final results to send to panel.
• Stopping criteria will be stability, not convergence of responses
• Stability will be measured by calculating the percent agreement from round to round.
Percent agreement greater than 80%will indicate stability (Stemler, 2004).

=DB

Appendix F

Tentative Study Timeline

Obtain IRB approval

Preparation 6 weeks
Interview questions reviewed for content and face validity
Provide prospective panel members with detailed
explanation of the Delphi technique, the purpose of the
study, and the time commitment for participation
Obtain consent from participants
Schedule Round One interviews
Round One 12 weeks
Conduct interviews with all panel members (audio record
and transcribe interviews)
Conduct content analysis for round one responses
Develop Round two survey
Round Two 5 weeks
Send Round two survey out to panel with clear directions
and due date for response (Due back in10 days)
Send follow-up email/phone call 5 days after initial survey
is sent to non-responders
Analyze round two data
Develop Round three survey
Round Three 5 weeks
Send Round three survey out to panel with clear directions
and due date for response (Due back in10 days)
Send follow-up email/phone call 5 days after initial survey
is sent to non-responders
Analyze round three data
Round Four 4 weeks
~Repeat procedure as described in round three if needed
Summarize findings and report to panel
Total ~8months

=DC

Appendix G

Demographics Survey

The following survey is designed to obtain demographic information about the participants who
have consented to participate in the expert panel for this study. The information obtained from
this survey will be combined and reported as a summary representing the group. Individual
responses are unidentifiable and confidential.
Thank you for taking the time to complete the survey. Your time and input is greatly appreciated.

1. Select the category below that includes your current age?

a. 18 to 23
b. 24 to 29
c. 30 to 35
d. 36 to 41
e. 42 to 47
f. 48 to 53
g. 54 to 59
h. > 59

2. What is your gender?

a. Female
b. Male

3. Please specify your ethnicity:

a. White
b. Hispanic or Latino
c. Black or African American
d. Native American or American Indian
e. Asian/ Pacific Islander
f. Other:

4. What is your highest level of education?

a. Associate’s degree
b. Bachelor’s degree
c. Master’s degree
d. Doctoral degree
e. Post doctoral studies

5. How many years have you been practicing since obtaining your initial licensure?
a. 1 to 3 years
b. 4 to 9 years
c. 10 to 15 years
d. 16 to 20 years
e. > 20 years ago

=DD

6. In what profession is did you obtain licensure?

a. Nursing
b. Medicine
c. Other:

7. How would you describe your role?

a. Staff nurse
b. Resident
c. Fellow
d. Attending
e. Nurse leader (please specify:____________________)
f. Physician leader (please specify:_________________)

8. What is the average number of hours you work per week?

g. 0-12 hours
h. 13-24 hours
i. 25-36 hours
j. 37-45 hours
k. > 45 hours

9. Which of the following best describes the setting in which you work?
a. Intensive care
b. Acute care, outside of the intensive care unit
c. Outpatient setting
d. Other (please specify)_______________________________________

10. How would you describe the nature of your work in regard to functioning within a
team?
a. I work within an intensive care unit (ICU) in which patient care is managed by the ICU
team.
b. I work in acute care, outside the ICU, where nurses staff the unit and individual
physicians follow patients under their care.
c. Other (please describe)___________________________________________

11. Which of the following best describes the type of institution in which you work?
a. Large academic teaching hospital
b. Community Hospital
c. Other: (please specify) _______________________________________

12. In the past month how many patients did you care for with a central venous catheter?
a. Less than 3
b. 4 to 8
c. 9 to 12
d. 12 to 15
e. More than 15

=DE

13. Is your institution currently using a CLABSI bundle or checklist?

a. Yes
b. No
c. Not sure

14. How many years of experience do you have working with an EHR?
a. <1 year
b. 1 to 3 years
c. 4 to 10 years
d. 11 to 15 years
e. 15 to 20 years
f. >20 years

=E<

Appendix H

Directed Content Analysis: Framework and Definitions of Predetermined Codes

Information type
• [Information] (what)
o [Artifact]- [Representational state] (where)
o Channels used to communicate
 Asynchronous- [channel] (how)
• Rule or norm- [Rule or norm]* (why for the how)
 Synchronous- [channel] (how)
• Rule or norm- [Rule or norm]* (why for the how)
o Channel that SHOULD be used to communicate
 Asynchronous- [channel] (how)
• Rule or norm- [Rule or norm]* (why for the how)
 Synchronous- [channel] (how)
• Rule or norm- [Rule or norm]* (why for the how)
Factors that influence use of EHR for communication^
• Factors that inhibit use
o [factors that inhibit use]
• Factors that promote use
o [factors that promote use]
*These should also be looked at as potential influencers of use of EHR for communication.
^May also be found in rules or norms that influence the use of a synchronous or asynchronous
channel.
[…] = labels to represent data found in transcripts

Definitions of codes:
(based on guiding frameworks & previous research)

Information = data that has been processed or structured within a context such that it provides
meaning (Matney, Brewster, Sward, Cloyes & Staggers, 2011).
Artifact = an information-bearing structure or tool that supports the exchange of information
(Hazlehurst et al., 2008). For example, an EHR.

=E=

Representational state = “is a particular configuration of an information-bearing structure, such

as a monitor display, a verbal utterance, or a printed label, that plays some functional role within
a process” (Hazlehurst et al., 2008, p. 228).
Asynchronous channel = describes a channel (or a means for sharing information) that does not
require the individuals to participate in the exchange at the same moment in time (Coiera et al.,
2002; Conn et al., 2009). This involves the use of asynchronous channels such as email, recorded
voice messages, or documentation in the patient record or electronic health record (EHR).
Synchronous channel = describes a channel (or means for sharing information) that occurs
when both individuals are present at the same moment in time during the exchange (Coiera et al.,
2002; Conn et al., 2009). This can occur, for example, via a channel that supports synchronous
exchanges from a distance, such as a telephone, through impromptu face-to-face discussions, or
in scheduled meetings, such as interprofessional rounds.
Rule or Norm = an aspect of the culture that influences interactions between the human actors in
the activity system (Hazlehurst et al., 2008).

=E>

Appendix I

Round 2 Survey


=E?

 =E@

6. Location of the CVC (e.g. IJ, SC, Femoral)

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

Optional: Rationale for response regarding location of

the CVC (e.g. IJ, SC, Femoral)

Expand

7. Number of intravenous medications being administered and whether they require central administration.
* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

Optional: Rationale for response regarding type and

number of medications being administered
intravenously

Expand

8. Number of days CVC has been in place

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

Optional: Rationale for response regarding number of

days CVC has been in place

Expand

9. Presence of other venous access

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset
 =EA

Optional: Rationale for response regarding presence of

other venous access

Expand

10. CVC insertion site condition

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

Optional: Rationale for response regarding CVC

insertion site condition

Expand

11. Reason the CVC was initially placed

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

Optional: Rationale for response regarding reason the

CVC was initially placed

Expand

12. What the CVC is currently being used for

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

Optional: Rationale for response regarding what the

CVC is currently being used for

Expand

=EB

13. Other information type not included above (please

specify):

Expand

Section II:
In this next section the focus is on how information related to CVCs
should be communicated among the interprofessional team in
order to support decisions to keep or discontinue the CVC.
Information may be communicated synchronously (typically oral) or
asynchronously (such as via the EHR). In some cases, for some
information types, more than one method of communication may
be warranted.

Oral or synchronous sharing can be scheduled (e.g.

interprofessional rounds) or non-scheduled. It is important to
recognize that non-scheduled oral communication can be
interruptive.

Asynchronous communication through the EHR can occur in

different ways. Clinicians may view documentation entered by
another team member by going to the original source of
documentation (e.g. read a procedure note or view the vital signs
flowsheet) or they may view data that is pulled from the original
documentation and then displayed in a patient level summary or
other visualization.

Directions:
For each information type indicate, from your perspective, the
ideal workflow for communicating this information with others on
the interprofessional team.

1. Conditions under which the central venous line was placed would be most effectively
communicated with the interprofessional team
 =EC

a. through the procedure note.

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset

Optional- Rationale for response:

Expand

b. through the physician's progress note.

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset

Optional- Rationale for response:

Expand

c. through the nurse's progress note.

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset

Optional- Rationale for response:

Expand

d. using a communication messaging tool (e.g., an electronic sticky note).

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset

=ED

 =EE

c. orally as soon as it is noted.

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset

Optional- Rationale for response:

Expand

c. Optional -Other channel (please specify):

Expand

3. Evidence of an infection may be based on patient temperature, lab results, and assessment of the
CVC insertion site. This information would be most effectively communicated with the
interprofessional team

a. orally as soon as there is a concern.

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset

Optional- Rationale for response:

Expand

b. orally during interprofessional team rounds.

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset

Optional- Rationale for response:

Expand

><<


><=


><>


><?


><@


><A


><B


><C


><D


><E


>=<


>==


>=>

Appendix J

Round 3 Survey


>=?


>=@

 >=A

Optional: Rationale for response regarding number of

days CVC has been in place

Expand

9. Presence of other venous access

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset
[100% of participants rated this as relevant (3) or highly relevant (4).]

Optional: Rationale for response regarding presence of

other venous access

Expand

10. CVC insertion site condition

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset
[90% of participants rated this as relevant (3) or highly relevant (4). Rationale provided: If looks bad, it is helpful. But otherwise not
that helpful. ]

Optional: Rationale for response regarding CVC

insertion site condition

Expand

11. Reason the CVC was initially placed

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset
[70% of participants rated this as relevant (3) or highly relevant (4).]

Optional: Rationale for response regarding reason the

CVC was initially placed

Expand
 >=B

12. What the CVC is currently being used for

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset
[100% of participants rated this as relevant (3) or highly relevant (4). Rationale provided: If conditions no longer met ie meds,
monitoring, labs]

Optional: Rationale for response regarding what the

CVC is currently being used for

Expand

13. Other information type not included above (please

specify):

Expand

>=C

 >=D

b. through the physician's progress note.

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset
[60% of participants rated this as somewhat agree (3) or agree (4). Rationale provided: Notoriously unreliable, unclear which CVC
referring to, not a natural place to look||very busy notes- would be difficult to find most relevant information]

Optional- Rationale for response:

Expand

c. through the nurse's progress note.

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset
[50% of participants rated this as somewhat agree (3) or agree (4). Rationale provided: not always||not a natural place to look||not
read by all participating disciplines]

Optional- Rationale for response:

Expand

d. using a communication messaging tool (e.g., an electronic sticky note).

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset
[60% of participants rated this as somewhat agree (3) or agree (4). Rationale provided: through the ehr's IV documentation. when,
where and how it was placed should be documented there||not always||not a natural place to look||accessible to all teams, though
sticky notes may not save to record]

Optional- Rationale for response:

Expand

>=E

 >><

Optional- Rationale for response:

Expand

d. Optional -Other channel (please specify):

(You may add another option or indicate your agreement with
one of the options provided below by typing it in this box.)

Expand
[from RN when discussing CVC on rounds]

3. Evidence of an infection may be based on patient temperature, lab results, and assessment of the
CVC insertion site. This information would be most effectively communicated with the
interprofessional team

a. orally as soon as there is a concern.

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset
[100% of participants rated this as somewhat agree (3) or agree (4). Rationale provided: as well as written]

Optional- Rationale for response:

Expand

b. orally during interprofessional team rounds.

* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset
[90% of participants rated this as somewhat agree (3) or agree (4). Rationale provided: may be hours after start of infection- could
have earlier intervention if noted straight away]

Optional- Rationale for response:

Expand

>>=


>>>


>>?


>>@


>>A


>>B


>>C


>>D


>>E


>?<


>?=


>?>


>??


>?@

 >?A

Appendix K

Round 4 Survey

Resize font:
|
Round 4 Survey for Leveraging documentation in the EHR to support
interprofessional communication

Please complete the survey below.

If needed, you may save the survey prior to completing and return at a later time to finish.

Thank you!

Thank you for your continued participation as an expert panel member. Your participation and
expertise is greatly appreciated!

**We are requesting that you complete one final survey round. This survey includes only 10 of the
original 68 items. We are asking you to re-rate these items because group consensus regarding whether
the items are relevant is unclear. Please consider adding rationale for these items as it will help us in
interpreting the results.**

You will notice that each item in this Round 4 survey again includes the aggregated responses and
rationale, if provided, from all panel members who completed the previous surveys. Please refer to this
information as well as your own previous responses (provided to you via email) when completing this
survey.

Once again there are three sections of the survey. Please see directions for completion at the beginning of
each section. The survey should take less than 20 minutes to complete.

If you have any questions you can contact: Jenna Thate at jthate@partners.org (518-812-6233) or Sarah
Collins at sacollins@partners.org. The Partners HealthCare Human Research Committee has approved
this study (protocol # 2016P001867).

Section I:
For the following items, review the responses of the other panel members provided below
each item and your previous response (provided in your email).

When less than 75% of participants rated an item as relevant or highly relevant, this item
is highlighted in yellow. This information is considered not necessary for making a
decision regarding whether to keep or discontinue a central line.

After reviewing this information, re-rate each item below. You may either select the same
rating you chose in the previous survey or you may change your response based on new
insight from the group summary and rationale.

-------------------------
Directions from previous survey:
For each item select how relevant you believe each type of information is to making decisions to keep or
remove a central venous catheter. If you would like to include a rationale for your response you may type it in the
space provided.
 >?B

11. Reason the CVC was initially placed

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

** In Round 2, only 70% of participants rated this as relevant (3) or highly relevant (4). In Round 3,
several participants changed their responses however, the item remained not relevant with 70% of
participants rating this item as a 3 or 4.

Rationale for response regarding the relevancy of

"reason the CVC was initially placed" to decisions about
whether to keep or discontinue a CVC.

Expand

Section II:
For the following items, review the responses of the other panel members provided below
each item and your previous response (provided in your email).

When less than 75% of participants selected somewhat agree or agree, this item is
highlighted in yellow. Thus, the channel is not an effective means for communicating the
information type being considered.

After reviewing this information, re-rate each item below. You may either select the same
rating you chose in the previous survey or you may change your response based on new
insight from the group summary and rationale.

-------------------------
Directions from previous survey:
In this next section the focus is on how information related to CVCs should be communicated among the
interprofessional team in order to support decisions to keep or discontinue the CVC. Information may be
communicated synchronously (typically oral) or asynchronously (such as via the EHR). In some cases, for some
information types, more than one method of communication may be warranted.

Oral or synchronous sharing can be scheduled (e.g. interprofessional rounds) or non-scheduled. It is important to
recognize that non-scheduled oral communication can be interruptive.

Asynchronous communication through the EHR can occur in different ways. Clinicians may view documentation
entered by another team member by going to the original source of documentation (e.g. read a procedure note or
view the vital signs flowsheet) or they may view data that is pulled from the original documentation and then
displayed in a patient level summary or other visualization.

Directions:
For each information type indicate, from your perspective, the ideal workflow for communicating this
information with others on the interprofessional team.

7. Number of intravenous medications that are being administered and whether they require central
administration would be most effectively communicated with the interprofessional team
 >?C

a. by flagging medications in the medication administration record (MAR) if they require central
administration.
* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset

** In Round 2, only 70% of participants rated this as somewhat agree (3) or agree (4). In Round 3, 80%
of participants rated this as a 3 or 4 indicating agreement that this is an effective means for
communicating this information. (Rationale provided in round 2: good place for the nurse...not
necessarily anyone else)

Rationale for response regarding "flagging medications

in the MAR":

Expand

b. by including the site of administration on the MAR for each medication (e.g., the time of last
administration of any IV medication would include the port and site of administration, such as, right,
internal jugular, proximal port or right forearm peripheral IV.)
* must provide value

1- disagree 2- somewhat disagree 3- somewhat agree 4- agree

reset

** In Round 2, 50% of participants rated this as somewhat agree (3) or agree (4). In Round 3, 70% rated
this as as a 3 or 4. The group's response is moving towards agree for this item. (Rationale provided in
round 2: doesn't help us now||changes frequently)

Rationale for response regarding "inclusion of site

administration on MAR":

Expand

c. orally during interprofessional team rounds.

** There was clear agreement that this is an effective means for communicating this information type. Therefore,
you are not being asked to re-rate this item.

Section III:
Factors that promote or inhibit the use of the EHR for interprofessional communication

-------------------------
Directions from previous survey:
For the following factors, rate how relevant each factor is in influencing the use of the EHR for communication
or information sharing.
 >?D

Factors that promote the use of the EHR for communication or information
sharing

For the following items, review the responses of the other panel members
provided below each item and your previous response (provided in your email).

When less than 75% of participants rated an item as relevant or highly relevant,
this item is highlighted in yellow. Thus, this item does not promote the use of the
EHR for communication.

After reviewing this information, re-rate each item below. You may either select the
same rating you chose in the previous survey or you may change your response
based on new insight from the group summary and rationale.

11. I am more apt to use the EHR to share information with someone in my discipline (nurse to nurse,
physician to physician).
* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

**In Round 2, 80% of participants rated this as relevant (3) or highly relevant (4). In Round 3, only 70%
of participants rated this at a 3 or 4 making this item not relevant

Rationale for item #11 in "factors that promote the use

of the EHR"

Expand

Factors that inhibit the use of the EHR for communication or information sharing

For the following items, review the responses of the other panel members
provided below each item and your previous response (provided in your email).

When less than 75% of participants rated an item as relevant or highly relevant,
this item is highlighted in yellow. Thus, this item does not inhibit the use of the
EHR for communication.

After reviewing this information, re-rate each item below. You may either select the
same rating you chose in the previous survey or you may change your response
based on new insight from the group summary and rationale.
 >?E

5. I don't know the workflow of other clinicians and therefore don't know where to look for certain types of
information.
* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

** In Round 2, 80% of participants rated this as relevant (3) or highly relevant (4). In Round 3, only 70%
of participants rated this as a 3 or 4 making this item not relevant.

Rationale for item #5 in "factors that inhibit the use of

the EHR"

Expand

6. Information is not accurate due to 'copy and paste' functionality.

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

** In Round 2, 60% of participants rated this as relevant (3) or highly relevant (4). In Round 3, 80% of
participants rated this as a 3 or 4 making this item relevant.

Rationale for item #6 in "factors that inhibit the use of

the EHR"

Expand

7. The relevant information is not in the EHR.

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

** In Round 2, 70% of participants rated this as relevant (3) or highly relevant (4). In Round 3, 90% of
participants rated this as a 3 or 4 making this item relevant.

Rationale for item #7 in "factors that inhibit the use of

the EHR"

Expand
 >@<

8. The EHR is not up-to-date.

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

** In Round2, 80% of participants rated this as relevant (3) or highly relevant (4). In Round 3, only 60%
of participants rated this item as a 3 or 4 making this item not relevant.

Rationale for item #8 in "factors that inhibit the use of

the EHR"

Expand

9. I can't have a discussion in the EHR.

* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

** In Round 2, 50% of participants rated this as relevant (3) or highly relevant (4). In Round 3, 70% of
participants rated this as a 3 or 4 moving this item towards relevant.

Rationale for item #9 in "factors that inhibit the use of

the EHR"

Expand

14. It takes too many "clicks" to find the information I am looking for.
* must provide value

1- not relevant 2- minimally relevant 3- relevant 4- highly relevant

reset

** In Round 2, 70% of participants rated this as relevant (3) or highly relevant (4). In Round 3, 80% of
participants rated this as a 3 or 4 making this item relevant.

Rationale for item #14 in "factors that inhibit the use of

the EHR"

Expand

>@=

List of Tables

Table 1. Sample Demographics for Expert Panel

Table 2. Round 2 Section I Results

Table 3. Round 2 Section II Results

Table 4. Round 2 Section III a Results

Table 5. Round 2 Section III b Results

Table 6. Round 3 Section I Results

Table 7. Round 3 Section II Results

Table 8. Round 3 Section III a Results

Table 9. Round 3 Section III b Results

Table 10. Round 4 Results

Table 11. Best Channel for Information Type with Asynchronous/Synchronous Designation

Table 12. Final Results for Factors that Promote the Use of the EHR

Table 13. Final Results for Factors that Inhibit the Use of the EHR

Table 14. Comparison of Indications for CVCs


>@>

List of Figures

Figure 1. Visual Model for Distributed Cognition Including the Concept of Common Ground

Figure 2. Influence of Common Ground on Use of a Synchronous or Asynchronous Channel

Figure 3 Impact of Complexity on Channel Selection as Compared to Common Ground