Electronic health record-supported implementation of an evidence-based pathway for perioperative surgical care

JunBo Wu; Christina T Yuan; Rachel Moyal-Smith; Elizabeth C Wick; Michael A Rosen

doi:10.1093/jamia/ocad237

Electronic health record-supported implementation of an evidence-based pathway for perioperative surgical care

J Am Med Inform Assoc. 2024 Feb 16;31(3):591-599. doi: 10.1093/jamia/ocad237.

Authors

JunBo Wu¹, Christina T Yuan^{1

2}, Rachel Moyal-Smith^{2

3}, Elizabeth C Wick⁴, Michael A Rosen¹

Affiliations

¹ Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States.
² Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States.
³ Ariadne Labs: A Joint Center of the Harvard School of Public Health and Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA 02215, United States.
⁴ Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, United States.

PMID: 38078843
PMCID: PMC10873834 (available on 2024-12-11)
DOI: 10.1093/jamia/ocad237

Abstract

Objectives: Enhanced recovery pathways (ERPs) are evidence-based approaches to improving perioperative surgical care. However, the role of electronic health records (EHRs) in their implementation is unclear. We examine how EHRs facilitate or hinder ERP implementation.

Materials and methods: We conducted interviews with informaticians and clinicians from US hospitals participating in an ERP implementation collaborative. We used inductive thematic analysis to analyze transcripts and categorized hospitals into 3 groups based on process measure adherence. High performers exhibited a minimum 80% adherence to 6 of 9 metrics, high improvers demonstrated significantly better adherence over 12 months, and strivers included all others. We mapped interrelationships between themes using causal loop diagrams.

Results: We interviewed 168 participants from 8 hospitals and found 3 thematic clusters: (1) "EHR difficulties" with the technology itself and contextual factors related to (2) "EHR enablers," and (3) "EHR barriers" in ERP implementation. Although all hospitals experienced issues, high performers and improvers successfully integrated ERPs into EHRs through a dedicated multidisciplinary team with informatics expertise. Strivers, while enacting some fixes, were unable to overcome individual resistance to EHR-supported ERPs.

Discussion and conclusion: We add to the literature describing the limitations of EHRs' technological capabilities to facilitate clinical workflows. We illustrate how organizational strategies around engaging motivated clinical teams with informatics training and resources, especially with dedicated technical support, moderate the extent of EHRs' support to ERP implementation, causing downstream effects for hospitals to transform technological challenges into care-improving opportunities. Early and consistent involvement of informatics expertise with frontline EHR clinician users benefited the efficiency and effectiveness of ERP implementation and sustainability.

Keywords: clinical pathway; electronic health records; health plan implementation; patient safety; perioperative care.

MeSH terms

Electronic Health Records*
Hospitals*
Humans
Motivation

Grants and funding

HHSP2332015000201/HH/HHS/United States