title: Health information exchange technology on the front lines of healthcare: workflow factors and patterns of use.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  The ethnographic qualitative study was conducted over a 9-month period in six emergency departments (ED) and eight ambulatory clinics in Memphis, Tennessee, USA. Data were collected using direct observation, informal interviews during observation, and formal semi-structured interviews. The authors observed for over 180 h, during which providers used the exchange 130 times.
  
  
  RESULTS
  HIE-related workflow was modeled for each ED site and ambulatory clinic group and substantial site-to-site workflow differences were identified. 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. The workflow elements framework was applied to the two role-based patterns. An in-depth description was developed of how providers integrated HIE into existing clinical workflow, including prompts for HIE use.
  
  
  CONCLUSIONS
  Workflow differed substantially among sites, but two general role-based HIE usage models were identified. Although providers used HIE to improve continuity of patient care, patient-provider trust played a significant role. 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. User and role-specific customization to accommodate differences in workflow and information needs may increase the adoption and use of HIE.
  
  
  CONCLUSIONS
  Understanding end users' perspectives towards HIE technology is crucial to the long-term success of HIE. By applying qualitative methods, an in-depth understanding of HIE usage was developed.
authors: Department of Biomedical Informatics, Vanderbilt Implementation Sciences Laboratory, Vanderbilt University School of Medicine, Nashville, Tennessee, USA. kim.unertl@vanderbilt.edu
authors: Kim M
authors: KM
authors: Unertl
authors: Kevin B
authors: KB
authors: Johnson
authors: Nancy M
authors: NM
authors: Lorenzi
mesh_terms: D000554:Ambulatory Care Facilities / Q000458:organization & administration; D003266:Continuity of Patient Care; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000458:organization & administration; D006801:Humans; D033181:Information Dissemination; D007373:Interinstitutional Relations; D008498:Medical Record Linkage; D009740:Nursing Staff; D010820:Physicians; D024382:Professional Role; D011369:Professional-Patient Relations; D013714:Tennessee; D035502:Trust; D057188:Workflow