Workarounds in Healthcare Technology

It’s probably safe to say that at some point in all our professional lives, we’ve used a workaround. Some of these were to accomplish a task related to an IT system or process. There may have been times when IT staff approved or even provided the workaround. Other times we may have been taught an easier way by some of our co-workers or even figured out a fun new ‘trick’ on our own. However, as great as they may seem .... not all workarounds are good and some can cause all sorts of issues we had no idea about.

To me, a workaround is an alternative path to accomplishing a task or series of tasks - that differs from the designed and intended process. Looking at a couple of definitions online, there is a bit of a negative focus. They tend to imply that the trigger point is a problem that needs fixing - I don’t think that’s always the case.

"(noun) A set of steps used to compensate for or avoid dealing with a systemic problem rather than fixing it."  Urban Dictionary

"(noun) Computers. A strategy or technique used to overcome a defect or other problem in a program or system." Dictionary.com

In our current world, the use of workarounds in health care can be broader then just overcoming defects or finding a way around significant issues .... sometimes it might just be about discovering another way to do something. There are many reasons why end-users develop and use workarounds to do things. Some may be single-use or steps that are only in place for a short time. While others are longer in duration and may even become the cultural norm.

Some key reasons for developing/following workarounds:

• Technical issues with the application. For example, the EHR slowing down or an error message/other barriers in completing the correct path. This includes the EHR/other application not having the option an end-user requires. (E.g. having to use a communication order with free text details if the desired order is not available in the catalog.)
• End user(s) not being sure/aware of how they should complete a task, or sequence of tasks, in the application.
• The workaround was informally taught by a colleague as the correct way (i.e. mimicking workarounds).
• End user(s) discovery of an alternate path within the system to accomplish the task or series of tasks. This is often done to improve workflow efficiency.
• The usability of the system takes too much time (real or perceived) and an external method is sought. (E.g. completing something on paper for it to be scanned in at a later time. Or, cut-pasting text entered in a word processing app to a free text section or generic type note within the EHR.)

Workarounds are almost always created and perpetuated with the best of intentions. But, they can result in some unfavorable outcomes for both patient care and process efficiency. This is often true even for positive workarounds.  When something is not known by all parties or isolated to a single user group/area - the ability to optimize the outcome is reduced. In many cases, the downstream impacts of workarounds may not be well understood. This can lead to individuals in a different area, at a different time, or with a different role experiencing impacts.

Some of the key impacts of technology workarounds.

1. Frustration. If everyone is not aware that a workaround is in place, individuals may become frustrated. For end-users, it may appear that certain activities have not been done.  For IT staff, or individuals designing future process flow - unknown workarounds can lead to misalignment. This may contribute to a culture where clinical staff and IT staff feel they do not understand each other.
2. Difficulty locating information. When users look for information, in real-time or at a later date, it can be hard to find if entered using a workaround.  It is also likely to take longer to locate things. With that, the risk of something getting missed altogether increases.
3. Downstream triggers. Applications are designed and configured with a particular flow/sequence in mind. Completing steps in a different place, or finding ways to change the order of steps can result in unanticipated technical issues. (For example, entering data in free text sections instead of the intended discrete fields may result in report impacts.)
4. Future changes. When unknown workarounds are in place, changes to workflow or technology becomes more difficult. Without an accurate sense of current state, it is not possible to communicate the changes in a comprehensive way. The risk of having something ‘break’ or not addressing an issue increase.
5. Training.  Efforts to train new users start to become anecdotal. The content of training materials and scenarios doesn’t match the ‘real world’. Trainers cannot share their in-depth system knowledge in a meaningful way if they are unable to incorporate accurate workflows in their materials and conversations.

As you can see from the above list, the impacts of workarounds can be far-reaching. They range from technical issues to delays in locating patient information. They can also lead to missing or misunderstanding documentation. (An article published in the Journal of Medical Internet Research (JMIR) provides some more in depth information on some of these impacts.)  

If the use of a workaround is discovered, or if a workaround is being considered, it is important to communicate to the appropriate individual(s). This may include representatives from the clinical departments, IT, or leadership groups. Hesitancy in communicating can result in some long term workflow impacts. Over time, these may compound and become increasingly difficult to manage.

In the next post, I will focus on how to evaluate a workaround. This will help determine if it is a positive that should be formalized; or, a negative that should be addressed and corrected. I’ll also provide some guiding principles to consider for the ongoing management of workarounds within your practice/health system.

"Patience and perseverance have a magical effect before which difficulties disappear and obstacles vanish." John Quincy Adams