Standardizing the shadow charting process used by Informatics Resource Nurses (IRNs) to test electronic health record (EHR) changes may improve nurse satisfaction with the EHR's usability. The project aims to identify if standardizing this process, which currently varies between facilities, will enhance data quality and implementation outcomes. A review of literature suggests shadowing actual workflow and understanding nurses' perceptions are important to adoption. Goals include assessing nurse and IRN satisfaction with the standardized process and its impact on nurses' usability satisfaction and workflow.

1. Will standardizing the shadow charting process improve nurses
satisfaction with the usability of the EHR?

2. Scope
 This project integrated nursing science, computer science, and
information science to manage and communicate data,
information, knowledge, and wisdom in nursing practice (ANA,
2008).
 The scope of this project is to identify if standardization of a
process used to support nurses use of the EHR will improve
their satisfaction with its usability.
 “......such a change can be brought about by improving
perceptions regarding the system, specifically perception of the
ease of system use and its usability in routine practice. Tailoring
interventions that are geared toward understanding nurses’
perceptions will promote adoption (Staggers, 2008).”

3. Standards
Problem & Issue Identification
Outcomes Identification
Assessment
Evaluation
Planning
Implementation
ANA, 2008

4. Baylor Health Care System (BHCS) Overview:

27 hospitals

26 ambulatory 
69 satellite outpatient
surgical/endoscopy centers
facilities

3, 534 licensed beds 
4 senior health centers

Research Institute 
2 retail pharmacies

19, 736 employees
 11,841 nurses
 4, 631 physicians
Electronic Health Record Implementation Efforts:
BHCS Materials & Website Interviews w/ Stakeholders

5. Shadow Charting Process Overview:
Overview
Part of the optimization effort used in the testing phase
of the change request process.
Tests for usability, workflow impact, and education/
training needs prior to implementation of enhancements
to the EHR.
Data generated is used to make recommendations to
Business Information Systems (BIS) to improve design.
Completing this process is the responsibility of the
Informatics Resource Nurses (IRNs).
BHCS Materials & Interviews w/ Stakeholders

6. Informatics Resource Nurse (IRN) Overview:
The IRN role was established to assess the fit of the EHR to
the needs of users.
Intended primary responsibilities are rounding & shadow
charting.
IRNs manage the change request process for their facility
including implementation of the change.
McCarty, Tyler & Quarterman, 2010
BHCS Materials & Observation,
Interviews w/ Stakeholders

7. Working Relationships of Optimizing Entities :
McCarty, Tyler & Quarterman, 2010

8. Problem:
 The IRN role and processes, including shadow charting, have
not been operationalised with variations at each site.
 With variations at each site the data integrity from the shadow
charting process is compromised.
 Introduction of enhancements to the EHR using this process
have negatively impacted users and workflow.
 A poor design adds time to the completion of work rather than
making it more efficient (Alexander & Staggers, 2009).
 Per Chris McCarty up to 99% of communications currently
resulting from this process are ineffective and do not reflect the
BHCS enterprise model.
McCarty, Tyler & Quarterman, 2010
Observation, Interviews w/ Stakeholders

9. Interactive Sociotechnical Analysis (ISTA) Theory
Four key features of ISTA:
• The importance of examining actual uses of HIT (“HIT-in-use”),
rather than uses that were planned or envisioned by designers or
managers.
• The impact on HIT use of technical and physical settings of work.
• Users’ renegotiation and reinterpretation of HIT features.
• Interaction and interdependence among social and technical
systems and recursive relations among sociotechnical
subcomponents.
Harrison, Koppel & Bar Lev, 2007

10. Interactive Sociotechnical Analysis (ISTA) Theory
The five interaction types are:
1 New HIT changes existing social system.
2 Technical & physical infrastructures mediate HIT use—
Interaction of new HIT with existing technical and physical
conditions affects HIT-in-use.
3 Social system mediates HIT use—Interaction of new HIT with the
social system affects HIT-in-use.
4 HIT-in-use changes social system—Interaction of new HIT with
the social system affects HIT-in-use, which then further changes
the social system.
5 HIT-social system interactions engender HIT redesign—
Interaction of new HIT with the social system affects HIT-in-use,
which then leads to changes in HIT properties.
Harrison, Koppel & Bar Lev, 2007

11. Application of Theory to IRN role & Shadow Charting Process
1. Examination of actual use-IRNs are positioned to interact
directly with clinical users. Shadow Charting examines
actual use.
2. Observation and Shadowing allow the IRN to take in to
account the technical and physical setting in use by nurses.
3. IRNs assess how nurses work around the current system,
and how they might work around the change.
4. The sociotechnical components: IRNs determine current
methods of communication and how change will affect those
methods.
Harrison, Koppel & Bar Lev, 2007

12. Literature Review
 Technography/Ethnography for the study of social–technical
configurations(Jansen & Vellema, 2011; Suchman, 1995).
 Shadowing...close following over a period of time to investigate
people...everyday lives, not what their roles dictate(Quinlan,
2008).
 Data grounded in actual events rather than reconstructions (focus
group and interviewing)(Quinlan, 2008).
 Shadowing suitable to answer questions within complex
interrelated processes (Quinlan, 2008).
 ...”the further removed we are from the work of others, the more
simplified, often stereotyped, our view of their work
becomes”(Suchman, 1995).

13. Literature Review
 Design of work environment linked to staff and patient safety,
efficiency, staff satisfaction, and errors. Excessive cognitive
workload.....(Battisto, Pak, Vander Wood & Pilcher, 2009).
 Complex Adaptive System. Until redesign ....... frustration,
inefficiencies, and suboptimal performance, including error
(Vardaman, Cornell & Clancy, 2012).
 Critical thinking requires time and control over workflow (Cornell,
Riordan,Townsend-Gervis & Mobley, 2011).
 Safety items and hand off communication not incorporated into
workflow or thinkflow causing workarounds; impede the flow of
and easy accessibility of patient information (Sidebottom,
Collins, Winden, Knuston & Britt, 2011; Staggers, Clark, Blaz &
Kapsandoy, 2011).

14. Literature Review

Undesirable outcomes of HIT implementation flow from
sociotechnical interactions—the interplay between new HIT and the
organization’s existing social and technical systems including their
workflows, culture, social interactions, and technologies.” (Harrison,
Koppel & Bar Lev, 2007).

When members of a natural system “perceive collective (at some
level) versus individual benefits, they are more willing to participate in
and, thus, sustain organizational initiatives” (Winiecki, 2010, p. 36).
(McCarty, Tyler & Quarterman, 2010).
Solutions that benefit many resonate in the “belief system” of the
IRN. Benefits to the collective whole should also be emphasized”

CD tests validity in the work environment...Ethnographic studies to

15. Shadow Charting Model
Receive Request
IRN Reviews
to Shadow Chart IRN
Request
After discussion with
Return item to Team Lead and IRN Pair up with a buddy
Is item Document in test
design team with No peers is item ready No and observe their
ready to be Yes environment.
recommendations. to be shadow workflow.
shadow
charted?
charted?
YES
Have buddy look
over documentation
in test environment.
Send Review findings
Discuss the change
recommendations during team Document and
and documentation
to implement or not meetings, with analyze findings .
with the buddy.
implement change Team Lead.

16. Goals & Evaluation
.

Core group of IRNs are responsible for educating their peers
and revising/updating the process as needed using
measurable criteria (i.e. IRN and nurse satisfaction surveys).

Assess nurse(s) and IRNs satisfaction with the shadow
charting process immediately after process completion & 1
month after implementation using a likert scale.

Nurse(s) satisfaction with usability will be assessed pre and
post implementation using a likert scale.

Checklist for shadow charting process will be used to collect,
track, and analyze data. Includes pre and post mapping of
nurses workflow, and subjective comments from nurses.

17. References
American Nurses Association (2008). Nursing Informatics Scope & Standards of Practice.
Silver Spring, MD: Nursebooks.org
Alexander, G.A., & Staggers, N. (2009). A systematic review on the design of clinical
technology: Findings and recommendations for future research. Advances in Nursing Science,
32(3), 252-279.
Battisto,D., Pak, R., Vander Wood, M., & Pilcher, J. (2009). Using a task analysis to describe
nursing work in acute care patient environments. Journal of Nursing Administration, 42(12),
538-547.
Cornell, P., Riordan, M., Townsend-Gervis, M., & Mobley, R. (2011). Barriers to critical thinking:
Workflow interruptions and task switching among nurses. Journal of Nursing Administration,
41(10), 407-414.
Harrison, M., Koppel, R., & Bar Lev, S. (2007). Unintended consequences of information
technologies in health care – An interactive sociotechnical analysis. JAMA, 14, 542-549.
Jansen, K., & Vellema, S. (2010). What is technography?. NJAS Wageningen Journal of Life
Sciences, 57, 169-177.

18. References
McCarty, C., Tyler, C., & Quarterman, S. (2010). Baylor Health Care System IRN
Competency Based Needs Assessment Final Report. Unpublished manuscript.
Optimization Education, BHCS, Dallas, TX.
Narasimhadevara, A., Radhakrishnan, B. L., Leung, B., & Jayakumar, R. (2008). On
designing a usable interactive system to support transplant nursing. Journal of Biomedical
Informatics, 41, 137-151.
Quinlan, E. (2008). Conspicuous invisibility: Shadowing as a data collection strategy.
Qualitative Inquiry, 14(8), 1480-1499.
Sidebottom, A.C., Collins, B., Winden, T., Knusten, A., & Britt, H.(2011) Reactions of nurses
to the use of electronic health record alert features in an inpatient setting. CIN: Computers,
Informatics, Nursing, 1-9.
Staggers, N., Clark, L., Blaz, J., & Kapsandoy, S. (2011). Why patient summaries in
electronic health records do not provide the cognitive support necessary for nurses’ handoffs
on medical and surgical units: Insights from interviews and observations. Health Informatics
Journal, 17(3), 209-223.

19. References
Staggers, N., Weir, C., & Pfansalkar, S. (2008). Patient safety and health information
technology: Role of Critical Elements of the Electronic Health Record. In R. Hughes
(Ed.), Patient Safety & Quality: an Evidence-based Handbook for Nurses (chapter 47).
AHRQ Publication No. 07-. Rockville, MD: Agency for Healthcare Research and
Quality. E-pub 4/08. Available at:
http://www.ahrq.gov/qual/nurseshdbk/docs/StaggersN_PSHIT.pdf. Published,
04/15/2008.
Suchman, L. (1995). Making work visible. Communication of the ACM, 38(9), 56-64.
Vardaman, J.M., Cornell, P.T., & Clancy, T.(2012). Complexity of change in nurse
workflows. Journal of Nursing Administration, 39(2), 78-82.