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Electronic health record (EHR) system users devise workarounds to cope with mismatches between workflows designed in the EHR and preferred workflows in practice. Although workarounds appear beneficial at first sight, they frequently jeopardize patient safety, the quality of care, and the efficiency of care.
This review aims to aid in identifying, analyzing, and resolving EHR workarounds; the Sociotechnical EHR Workaround Analysis (SEWA) framework was published in 2019. Although the framework was based on a large case study, the framework still required theoretical validation, refinement, and enrichment.
A scoping literature review was performed on studies related to EHR workarounds published between 2010 and 2021 in the MEDLINE, Embase, CINAHL, Cochrane, or IEEE databases. A total of 737 studies were retrieved, of which 62 (8.4%) were included in the final analysis. Using an analytic framework, the included studies were investigated to uncover the rationales that EHR users have for workarounds, attributes characterizing workarounds, possible scopes, and types of perceived impacts of workarounds.
The SEWA framework was theoretically validated and extended based on the scoping review. Extensive support for the pre-existing rationales, attributes, possible scopes, and types of impact was found in the included studies. Moreover, 7 new rationales, 4 new attributes, and 3 new types of impact were incorporated. Similarly, the descriptions of multiple pre-existing rationales for workarounds were refined to describe each rationale more accurately.
SEWA is now grounded in the existing body of peer-reviewed empirical evidence on EHR workarounds and, as such, provides a theoretically validated and more complete synthesis of EHR workaround rationales, attributes, possible scopes, and types of impact. The revised SEWA framework can aid researchers and practitioners in a wider range of health care settings to identify, analyze, and resolve workarounds. This will improve user-centered EHR design and redesign, ultimately leading to improved patient safety, quality of care, and efficiency of care.
Electronic health record (EHR) systems are the backbone of modern health care organizations. This is in pursuit of promising gains in patient safety, quality of care, efficiency, and control of spiraling costs by enabling value-based reimbursements. However, realizing these expected benefits is far from a given value. Over the years, an overwhelming number of studies have reported that EHRs have led to a multitude of unintended consequences. Examples include potential patient harm resulting from bad EHR usability [
Many causes of unintended consequences of EHR use can be traced back to discrepancies between the behavior, intentions, and expectations of EHR users and the workflows dictated by EHRs [
Blijleven et al [
The SEWA framework [
To address these shortcomings, a scoping literature review was performed to identify and map the available evidence on EHR workarounds [
The MEDLINE, Embase, CINAHL, Cochrane, and IEEE databases were searched for relevant studies. We included original, full papers of research with empirical data and conference papers if there were no full papers published in the same study.
Search queries used for the scoping review.
Date of search | Database | Query |
April 9, 2021 | MEDLINE |
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April 9, 2021 | Embase |
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April 9, 2021 | CINAHL |
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April 9, 2021 | IEEE |
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April 9, 2021 | Cochrane |
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The inclusion and exclusion criteria were chosen through discussions among the reviewers (FH, VB, and MJ). As the focus of this scoping review was on workarounds in EHR use, it was decided to exclude studies focused on barcode medication administration systems as these systems serve only 1 purpose and cover only a small part of the medication process. Furthermore, the choice was made to exclude research focused on EHR functionalities other than those aimed at supporting the clinical process. To ensure data quality, a study was excluded if the research methods were not reported or in case the study had not been peer reviewed. Furthermore, research published before 2010 was excluded as EHRs have undergone significant changes and improvements over the years. Finally, the inclusion and exclusion criteria were chosen.
The study inclusion criteria were as follows:
The health care setting of the study must be either ≥1 of primary, secondary, or tertiary care.
Workarounds were studied or reported in the context of EHR use.
The article was published between 2010 and 2021.
Studies were excluded if they met any of the following criteria:
The research focused on EHR functionalities other than those aimed at supporting within the clinical process.
The research focused on a barcode administration functionality.
The article was not written in English.
There was no access to the full-text article.
The article was not peer reviewed.
The research methods were not reported.
A literature search was conducted in April 2021. A total of 737 potentially relevant studies were retrieved from our initial search of electronic databases, more specifically MEDLINE (263/737, 35.7%), Embase (121/737, 16.4%), CINAHL (89/737, 12.1%), IEEE (58/737, 7.9%), and Cochrane (206/737, 27.9%). The results of the study selection process are shown in the PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) flowchart in
PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) flowchart of the study selection process. CPOE: computerized physician order entry; EHR: electronic health record.
The retrieved 737 studies were uploaded to EndNoteX9 (Clarivate), in which duplicates were first removed by both using EndNoteX9 and by performing a manual check (
Descriptive data from the included articles, such as title, authors, year of publication, study setting, functionalities of EHR studied, and research methods used, were captured in a generic overview per study (
The data extracted from the included articles were compared with the SEWA framework on a study-by-study basis. In doing so, SEWA was supplemented with new rationales, attributes, possible scopes, and types of impact of EHR workarounds that were not previously included. After the analysis was completed, an updated (graphical) version of the SEWA framework was created.
The general characteristics of the 62 studies are shown in
General characteristics of the included studies (N=62).
Study characteristics | Values, n (%) | |
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2010-2015 | 30 (48) |
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2016-2021 | 32 (52) |
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Primary care | 18 (29) |
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Secondary care | 21 (34) |
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Tertiary care | 23 (37) |
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Medication-related (eg, prescribing and CPOEb) | 17 (27) |
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Documentation | 8 (13) |
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Overall EHR | 28 (45) |
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Others (eg, alert systems and authentication process) | 9 (15) |
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Physicians | 9 (15) |
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Nurses | 13 (21) |
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Others (eg, pharmacists or administrative staff such as managers, |
12 (19) |
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Combination of users | 28 (45) |
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Observations | 7 (11) |
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Interviews | 15 (24) |
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Questionnaires | 5 (8) |
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Others (eg, think-aloud and documentation analysis) | 9 (15) |
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Combination of ≥1 observation, interview, questionnaire, or other | 26 (42) |
aEHR: electronic health record.
bCPOE: computerized physician order entry.
Evidence for the work system components, rationales, attributes, type of impact, and possible scopes contained in the original SEWA framework was found in the included studies. Moreover, we refined and enriched the original framework with 7 rationales, 4 attributes, and 3 types of impact. The following subsections elaborate on the work system components, rationales, attributes, possible scopes, and types of impact.
Support for all 5 work system components was found in the included studies, as shown in
Overview of work system components and related included studies.
Work components | Description | Studies |
Person(s) | Health care professionals developing and using EHRa workarounds | [ |
EHR system and related technology | The EHR and related information technology used by health care professionals | [ |
Organization | Organizational conditions (eg, care directives and hospital policies) under which clinical tasks and EHR use are performed | [ |
Physical environment | The environment (eg, outpatient examination room and inpatient ward) and its conditions (eg, lighting and noise) in which clinical tasks are conducted by health care professionals | [ |
Task(s) | Clinical tasks performed by health care professionals | [ |
aEHR: electronic health record.
The rationales for workarounds contained in the original SEWA framework were confirmed in many studies. In addition, 7 new rationales were identified.
Under the work system component
Although extensive support in the included studies was found for all rationales under the work system component
Multiple studies provide support for all rationales under the work system component
Although support was found for the pre-existing rationales under
Finally, the SEIPS work system component
Overview of rationales for the work system component person(s) and related included studies.
Rationales | Description | Studies |
Declarative knowledge | Not knowing how to use (a part of) the EHRa to accomplish a task | [ |
Procedural knowledge | Knowing how but not being proficient enough to use a part of the EHR to accomplish a task | [ |
Memory aid | Writing patient data down on paper (eg, keywords) or adding visual elements to parts of text in a progress note (eg, boldfacing, italicizing, or underlining) to remind oneself | [ |
Awareness | Storing patient data that are perceived important by the EHR user for other colleagues or patients to be noticed (frequently in a data field other than the intended field in the EHR) | [ |
Social norms | Formal or informal, collaborative, and cultural understandings among health care professionals leading to the creation and dissemination of workarounds (eg, mimicking workarounds devised by colleagues to accomplish a task or working around the system upon as friendly requested or enforced by a fellow clinician) | [ |
Trust (new) | Having insufficient trust in the (new) EHR system or its capabilities, lack of perceived usefulness, or insufficient confidence in the (completeness) of data | [ |
aEHR: electronic health record.
Overview of rationales for the work system component EHRa system and related technology and related included studies.
Rationales | Description | Studies |
Usability | High behavioral user cost in accomplishing a task | [ |
Technical issues | (A part of the) EHR or ancillary technology halting, crashing, or slowing down, hampering the EHR user in accomplishing a task | [ |
Data presentation | Preferring a different data view (eg, visualization by means of charts or graphs rather than plain text) | [ |
Patient data specificity | Needing to enter or request patient data with greater or lesser specificity than offered or enforced by the EHR | [ |
Data integration (new) | EHR not providing or supporting the integration of patient data necessary for care delivery | [ |
Enforced actions (new) | Avoiding or overriding actions enforced by the EHR (eg, bypassing the approval process of prescribing medication or using a different user account) | [ |
Data quality (new) | Unavailability of data, disparity in data formats (eg, the same data being stored in multiple different formats in the EHR), lack of standardization, and information gaps in the EHR | [ |
Interoperability (new) | Data not able to be exchanged between health care systems or institutions (eg, causing data to be unavailable at the right moment and time) | [ |
aEHR: electronic health record.
Overview of rationales for the work system component organization and related included studies.
Rationales | Description | Studies |
Efficiency | Using an alternative way of accomplishing a task that improves actual efficiency | [ |
Data migration policy | Not having (direct) access to required historical data because of data not having been imported from previously used systems to the current EHRa | [ |
Enforced data entry | EHR enforcing user to enter patient data of which neither the user nor the patient has knowledge of | [ |
Required data entry option missing | EHR not offering the required data entry option (eg, 3.75 mg rather than the available options 2.5 mg or 5 mg) | [ |
aEHR: electronic health record.
Overview of rationales for the work system component task(s) and related included studies.
Rationales | Description | Studies |
Task interference | Inability to perform multiple tasks at once (eg, simultaneously treating a patient on the treatment table as well as entering patient data into the EHRa) | [ |
Commitment to patient interaction | Valuing patient interaction over computer interaction (ie, writing things down on paper and afterward entering this into the EHR) | [ |
Task complexity (new) | The high complexity of the tasks needing to be conducted | [ |
aEHR: electronic health record.
Although several studies confirmed the previously defined attributes in SEWA, several included studies also mentioned a total of 4 new attributes (
Overview of workaround attributes and related included studies.
Attributes | Description | Source |
Cascadedness | Whether the workaround initiates the creation of 1 or multiple additional workarounds or is an isolated occurrence | [ |
Avoidability | Whether the workaround is required to proceed with one’s workflow or optional | [ |
Anticipatedness | Whether the workaround is used at known moments in time (ie, the situation in which the workaround is used is known beforehand) or used unexpectedly | [ |
Repetitiveness | Whether the workaround is ingrained into the workflow (ie, becomes part of daily routines) or used temporarily to overcome workflow constraints | [ |
Awareness (new) | Whether the user is aware of using the workaround | [ |
Shared (new) | Whether the workaround is a shared practice across multiple other users of the EHRa or limited to 1 user | [ |
Medium (new) | On what medium the workaround is conducted (eg, paper, computer, verbal, or a combination) | [ |
Formality (new) | Whether the use of the workaround is approved by management and part of a defined process | [ |
aEHR: electronic health record.
The previously defined types of impact in the SEWA framework were confirmed by many included studies. Multiple additional types of impact were also identified:
Overview of types of impact and related included studies.
Impact | Description | Source |
Patient safety | The impact on the safety (physical and mental) of the patient | [ |
Effectiveness of care | The effectiveness and quality of the care process performed | [ |
Efficiency of care | The impact on the efficiency of the care process in terms of time and resources expended | [ |
Privacy and security (new) | Impact on the security and privacy of data related to the patient or organization | [ |
Data quality (new) | Impact of workarounds on data quality (eg, loss of data or decreased data quality) | [ |
Financial (new) | Financial implications because of the workaround | [ |
Laws and regulations (new) | Legal conflicts resulting from the use of a workaround | [ |
Workload (new) | An increase or decrease in workload of the EHRa user resulting from the use of a workaround | [ |
aEHR: electronic health record.
Only a few studies explicitly discussed possible scopes (ie, entities impacted) of workarounds and resonated with those in the SEWA framework [
Overview of possible scopes and related included studies.
Scope | Description | Source |
Patient | The workaround affects the patients in the care process | [ |
Health care professional | The workaround affects the health care professionals such as physicians, nurses, and pharmacists | [ |
Organization | The workaround affects the whole organization, including the supporting departments such as finance or legal | [ |
On the basis on the foregoing results, the original SEWA framework [
Revised SEWA framework with incorporated rationales, attributes, types of impact, and possible scopes identified in included studies. EHR: electronic health record; SEWA: Sociotechnical Electronic Health Record Workaround Analysis.
The recommendations [
A scoping review was performed to theoretically validate the SEWA framework [
The results of this scoping review are in line with prior research and reviews of EHR workarounds. In an integrative review, Fraczkowski et al [
To maximize the capture of relevant information on EHR workarounds, comprehensive and structured searches were conducted in MEDLINE, Embase, CINAHL, Cochrane, and IEEE databases. Data charting templates and analytic frames were used to extract relevant information from the reviewed studies and compare with pre-existing items in the SEWA framework.
A total of 2 research team members participated in the review process for both the title and abstract and full-text review phases, with a Cohen κ value of >0.9. This indicates an adequate interrater agreement. Despite this, our scoping review is at risk for selection bias, as we did not identify all available data, such as gray literature on EHR workarounds. There is a chance that relevant but nonincluded studies may use terminology other than the terms included in the search queries.
The broad scope of the retrieved information on EHR workarounds and the different types of studies reporting a particular issue made using a formal meta-analytic method to quantitatively assess the quality of the studies and evidence of retrieved information difficult. However, given the purpose of the scoping review to theoretically validate and refine the SEWA framework, we do not consider this limitation.
Multidisciplinary teams (comprising, for example, physicians, nurses, management, and EHR developers) can use the revised SEWA framework to identify, analyze, prioritize, and resolve workarounds related to EHR use more accurately. Similarly, the consequences of current and future configurations of the work system (health care professionals’ work processes and activities in relation to their EHR use) can be assessed and discussed in greater detail to determine how a design and redesign of the work system would positively or negatively affect the interaction between work system components. Finally, as workarounds are subject to gradual change (eg, personal changes in experience with the EHR, system updates to the EHR, and hospital policies), more detailed snapshots of the work system using SEWA can be taken over time and compared so as to gain valuable insights into how EHR workarounds evolve over time.
Concerning future research, EHR systems are continuously subject to technological evolution by developments in, for example, artificial intelligence, machine learning, and telemedicine. This may lead to the creation of hitherto unidentified rationales, attributes, possible scopes, and types of impact of workarounds on users, patients, and health care organizations. Similarly, more studies on EHR workarounds will continue to emerge that may report novel insights not incorporated into the revised SEWA framework. Therefore, we expect that SEWA needs a continuous process of refinement over time. This could be done by repeating the scoping review using the described search strategy, search queries, and inclusion and exclusion criteria.
In addition, although the revised SEWA framework is now theoretically validated, refined, and enriched, practical validation is still required. The same holds true when investigating its practicality. The firsthand experience from the application of SEWA in practice could yield suggestions for further improvement. A related suggestion is that although the framework helps in identifying and analyzing workarounds, a prioritization method for handling these issues is likely required, as workarounds are generally abundant in any organization, and resources to resolve them are finite. Therefore, the framework could benefit from being extended with prioritization mechanisms and weighting factors for deciding which workarounds require priority. Similarly, the framework could be translated into a practical tool such as a scoring matrix to facilitate use by practitioners.
Finally, the applicability of the SEWA framework could be explored for systems other than EHRs (eg, enterprise resource planning, customer relationship management, and content management) and in other settings (eg, nonacademic hospitals and general practitioner practices) and even in other industries (eg, financial services and manufacturing) after appropriate validation. Although SEWA has an explicit focus on EHRs used in health care, we expect many of the described workaround rationales and attributes to be applicable to other systems, settings, and industries.
Descriptive data template that was captured per included study.
Analytic frame with workaround-related data captured per study.
electronic health record
Preferred Reporting Item for Systematic Reviews and Meta-Analyses
Systems Engineering Initiative for Patient Safety
Sociotechnical Electronic Health Record Workaround Analysis
VB, FH, and MJ conceived and designed the study. FH collected the data. VB and FH analyzed the data and wrote the manuscript. VB and MJ edited the manuscript. All authors read and approved the final manuscript.
None declared.