In part 1 (September 2010 issue), we discussed the chaotic nature of nurse activities and its implications on transforming workflow. To assess the impact of new technology on nurse workflow, nurses at 2 hospitals were observed before and after implementation of an electronic medication charting system. By applying qualitative methods, an in-depth understanding of HIE usage was developed. Understanding end users' perspectives towards HIE technology is crucial to the long-term success of HIE. User and role-specific customization to accommodate differences in workflow and information needs may increase the adoption and use of HIE. Types of information retrieved related to roles, with nurses seeking to retrieve recent hospitalization data and more open-ended usage by nurse practitioners and physicians. Although providers used HIE to improve continuity of patient care, patient-provider trust played a significant role. Workflow differed substantially among sites, but two general role-based HIE usage models were identified. An in-depth description was developed of how providers integrated HIE into existing clinical workflow, including prompts for HIE use. The workflow elements framework was applied to the two role-based patterns. Common patterns in HIE-related workflow were also identified across all sites, leading to the development of two role-based workflow models: nurse based and physician based. HIE-related workflow was modeled for each ED site and ambulatory clinic group and substantial site-to-site workflow differences were identified.

The authors observed for over 180 h, during which providers used the exchange 130 times. Data were collected using direct observation, informal interviews during observation, and formal semi-structured interviews. The ethnographic qualitative study was conducted over a 9-month period in six emergency departments (ED) and eight ambulatory clinics in Memphis, Tennessee, USA. The goal of this study was to develop an in-depth understanding of how a health information exchange (HIE) fits into clinical workflow at multiple clinical sites.

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