Managing Medication Plans When Information Is Scattered: Clinicians' Strategies and Tools

Paper Title

Managing Medication Plans When Information Is Scattered: Clinicians' Strategies and Tools

Publication Info

• Topic area: Medication management in fragmented electronic health record (EHR) systems.
• Keywords: Medication management, EHR fragmentation, repair work, clinician strategies, personalized tools, information substrates, healthcare IT, workflow adaptation, malleable systems, clinical improvisation.

Background and Problem

• Problem / challenge: Medication management workflows are fragmented across heterogeneous EHR systems, requiring clinicians to manually reconcile and translate information. Current systems fail to support clinicians' improvisational strategies for handling breakdowns.
• Significance: Medication errors, often caused by system fragmentation, can lead to serious patient harm. Addressing this issue is critical for improving patient safety and workflow efficiency.
• Motivation and related work: Prior research has focused on automating data transfer and formalizing workarounds into EHR features. However, these approaches are inadequate for unpredictable, non-standard clinical scenarios. This paper builds on the concept of "repair work" to explore how clinicians adapt to system limitations.

Solution

• Proposed approach: Design flexible tools that explicitly support clinicians' improvisational strategies for managing medication plans across fragmented systems.
• Novelty:
  1. Identification of personalized repair strategies (shortcuts, tweaks, and translation) used by clinicians.
  2. Proposal of malleable tools, such as macros, interaction substrates, and personal workspaces, to support repair work.
  3. Application of the "information substrates" concept to medication management in safety-critical environments.
  4. Emphasis on enabling clinicians to construct in situ solutions rather than rigidly formalizing workflows.
• Procedure and key techniques:
  • Conducted two studies: a 144-hour field study in a German hospital and group interviews with 20 clinicians across Germany and France.
  • Analyzed clinicians' strategies for managing medication information, focusing on personalized tools and artifacts.
  • Proposed design implications based on observed repair work practices.

Results

• Concrete findings:
  • Clinicians developed personalized strategies, including selective cues, pointers, and external artifacts, to manage fragmented medication data.
  • System fragmentation led to errors such as incomplete transfers, transcription mistakes, and poor traceability.
  • Clinicians created tools like spreadsheets, text templates, and backup artifacts to address system limitations.
• Advantage over baselines:
  • Proposed tools (macros, anchors, personal workspaces) directly address the limitations of rigid EHR systems by supporting flexibility and traceability.
  • Shift from formalizing past workarounds to enabling real-time, adaptive solutions.
• Experiments / evaluation:
  • Study 1: Observed 11 clinicians in a German hospital, documenting 136 medication management situations.
  • Study 2: Conducted group interviews with 20 clinicians from diverse settings in Germany and France, analyzing 129 quotes about medication management.
• Limitations and future work:
  • Study 1 was limited to a single hospital and primarily involved residents. Study 2 had logistical challenges and fewer nurse participants.
  • Future research should explore broader institutional contexts, include more diverse roles, and refine participatory design methods.

Summary

This paper investigates how clinicians manage medication plans in fragmented EHR systems, revealing that they rely on personalized strategies and external tools to address system limitations. Through field observations and interviews, the authors identified three key repair strategies: shortcuts, tweaks, and translation. They propose designing flexible tools, such as macros, interaction substrates, and personal workspaces, to support these strategies. By treating the infrastructure as a malleable substrate, the proposed tools aim to empower clinicians to navigate diverse representations while maintaining safety and efficiency in medication management. This approach shifts the focus from rigid standardization to enabling adaptive, context-specific solutions.