“CATCH-IT Reports” are Critically Appraised Topics in Communication, Health Informatics, and Technology, discussing recently published ehealth research. We hope these reports will draw attention to important work published in journals, provide a platform for discussion around results and methodological issues in eHealth research, and help to develop a framework for evidence-based eHealth. CATCH-IT Reports arise from “journal club” - like sessions founded in February 2003 by Gunther Eysenbach.

Monday, November 23, 2009

Final CATCH-IT Report: User-designed information tools to support communication and care coordination in a trauma hospital

Gurses AP, Xiao Y, Hu P. User-designed information tools to support communication and care coordination in a trauma hospital. J Biomed Inform. 2009 Aug;42(4):667-77.

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This report provides an appraisal of the study presented by Gurses and colleagues (2009) entitled User-designed information tools to support communication and care coordination in a trauma hospital. A nurse coordinator’s clipboard, a paper-based information tool compiled from a variety of information sources is examined using the qualitative methods of shadowing, interviews, photographs, and samples of the clipboards.

The authors determine that clinicians will create their own tools and it is necessary to describe and understand the characteristics of these information tools used in practice. They conclude that uncovering strategies developed to ‘work around’ disparate systems may identify unrecognized needs not taken into account by system designers.

The aim of the study was to describe the design characteristics and use of a clinician-designed information tool constructed to support information transfer and care coordination. Specifically, this was a clipboard that nurse coordinators assembled by compiling data from a variety of sources, such as electronic medical records and physician on-call schedules. They manually blocked out non-essential information, cut and pasted print-outs, and re-assembled data onto one clipboard.

Six nurse coordinators in an urban, academic trauma hospital agreed to participate in the study. Qualitative methods included shadowing plus recorded voice communication, as well as semi-structured interviews, photographs, and samples of clipboards from six consecutive shifts. Content analysis was conducted on observation transcripts, interview transcripts, photographs, and samples of clipboards. Ethnographic methods were initially stated as the analytical approach. Later, a grounded theory approach was identified specifically for analyzing the clipboards. No paradigm framework or philosophical assumptions were described.


A paper-based tool was assembled by nurse coordinators by drawing from a variety of information sources, some of them electronic. This process was outlined as taking data from various sources and, 1) selecting and formatting, 2) reducing, 3) bundling, and 4) annotating. On average, this tool took 41 minutes to put together and was done twice each day. Assembling this tool was done in efforts to increase the 1) compatibility of information, 2) rapid access to information, and 3) rapid processing of information.

These results are comparable to other studies offering descriptions of information tools created by clinicians outside of electronic systems to assist their work (Varpio 2006, Gorman 2000, Saleem 2009).

The authors do not take the opportunity to appraise the reader of their philosophic assumptions. Qualitative research is value-laden and researchers can explicitly state those values by declaring their worldviews or philosophic assumptions, providing the reader with a transparency helpful when appraising their work (Creswell 2007; Guba & Lincoln 2005). As well, the authors use two analytic approaches, ethnographic methods and grounded theory, but offer no further explanation necessary for the reader to understand this strategy.

Although six nurse coordinators gave their permission to participate in the study, one did not take part in the interviews without an explanation provided for their exclusion. At the same time, it was not indicated that data saturation was attained in the description of the analysis. Limited information is offered about the interviews, the photographs, and the clipboards in comparison to the reporting on shadowing. For instance, interviews lacked descriptions about their length, the use of field notes to supplement the interviews, or the number of researchers involved in conducting interviews.

Activities such as the pre-testing of the observation instrument are summarized but not explicitly identified as a pre-test for the reader. Similarly, the use of more than one method of data collection suggests that the authors may have been using triangulation to substantiate findings; however this is not clearly labeled and clarification is not given on how it was achieved. Respondent validation could have been considered for this study to add to validity and credibility to the findings (Guba & Lincoln, 2005).

This study offers insight into design characteristics and contextual information about a clinician-developed information tool. Although one group of clinicians is examined in one hospital, it contributes to a growing body of work that identifies the widespread use of user-designed tools (Halbesleben 2008, Varpio 2006, Gorman 2000, Saleem 2009). It describes how processes to design systems may not meet the needs of practitioners and offers a rich illustration of this captured with methods such as shadowing and photographs. By finding agreement upon the definition of an information transfer event, the authors were able to identify that the clipboard being studied was used more often than other information sources by the nurse coordinators, and concluded the features of the clipboard such as portability and rapid accessibility outweighed accuracy.

The findings offer a demonstration of aspects of user-interface design that can be overlooked. The authors describe the complexity of work in clinical settings, and suggest that it may be impossible to design systems that accurately meet clinician’s needs at all times. It is suggested that design processes may not readily be able to demarcate a clear beginning or end since needs are constantly evolving. They advise that the realities of complex clinical work environments providing appropriate support for clinicians require moving flexibility and adaptability to the forefront of design. Hybrid models of electronic and paper-based information tools may provide the most effective tools in accommodating the needs of practitioners in clinical settings.

Questions for Authors
  • Do the authors have a paradigm framework or worldview that could be declared?
  • Why were the analytical approaches of ethnographic methods and grounded theory mixed?
  • What were the reasons for not including an interview with one nurse coordinator?
  • Would it have been possible to use respondent validation with the nurse coordinators?
  • Which of the researchers conducted the interviews? Were field notes used to supplement the interviews?
  • Was data saturation reached?

Creswell, John W. Qualitative inquiry and research design: Choosing among five approaches. 2nd edition. Thousand Oaks CA: Sage Publications, 2007.

Gurses AP, Xiao Y, Hu P. User-designed information tools to support communication and care coordination in a trauma hospital. J Biomed Inform. 2009 Aug;42(4):667-677.

Gorman P, Ash J, Lavelle M, Lyman J, Delcambre L, Maier D. Bundles in the wild: managing information to solve problems and maintain situation awareness. Libr Trends 2000;49(2):266–289.

Guba EG, Lincoln YS. Paradigmatic controversies, contradictions, and emerging influences. In: Denzin NK, Lincoln YS, eds. The Sage Handbook of Qualitative Research. 3rd edition. Thousand Oaks CA: Sage Publications, 2005: 191-215.

Halbesleben JR, Wakefield DS, Wakefield BJ. Work-arounds in health care
settings: Literature review and research agenda. Health Care Manage Rev. 2008

Saleem JJ, Russ AL, Justice CF, Hagg H, Ebright PR, Woodbridge PA, Doebbeling BN. Exploring the persistence of paper with the electronic health record. International Journal of Medical Informatics 2009; 78:618-628.

Varpio L, Schryer CF, Lehoux P, Lingard L. Working off the record: Physicians’ and nurses’ transformations of electronic patient record-based patient information. Academic Medicine 2006;81(10):S35–S39.

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