Electronic communication and collaboration in a health care practice

Artificial Intelligence in Medicine 12 (1998) 137–151

Electronic communication and collaboration in ahealth care practice1

Charles Safran a,b,*, Peter C. Jones b, David Rind a,b, Booker Bush a,Kayla N. Cytryn c, Vimla L. Patel c

a Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline A6e., Boston,MA 02215, USA

b Center for Clinical Computing, Har6ard Medical School, 350 Longwood A6e., Boston,MA 02115, USA

c Cogniti6e Studies in Medicine: Centre for Medical Education, McGill Uni6ersity, 1110 Pine A6e W.,Montreal, Qc H3A 1A3, Canada

Received 31 December 1996; received in revised form 31 July 1997; accepted 1 September 1997

Abstract

Using cognitive evaluation techniques, this study examines the effects of an electronicpatient record and electronic mail on the interactions of health care providers. We find thatthe least structured communication methods are also the most heavily used: face-to-face,telephone, and electronic mail. Positive benefits of electronically-mediated interactionsinclude improving communication, collaboration, and access to information to supportdecision-making. Negative factors include the potential for overloading clinicians withunwanted or unnecessary communications. © 1998 Elsevier Science B.V.

Keywords: Collaboration; Electronic mail; Electronic patient records; Decision support;Evaluation

* Corresponding author. Tel.: +1 617 6671596; fax: +1 617 6671002; e-mail: [email protected] The study was in part supported by a cooperative agreement with the Agency for Health Care Policy

and Research and the National Library of Medicine (U01HS08749), and in part by the Social Sciencesand Humanities Research Council of Canada (No. 410-95-1206).

0933-3657/98/$19.00 © 1998 Elsevier Science B.V. All rights reserved.

PII S0933 -3657 (97 )00047 -X

C. Safran et al. / Artificial Intelligence in Medicine 12 (1998) 137–151138

1. Introduction

The electronic patient record that was developed and is now deployed at the BethIsrael Deaconess Medical Center has fundamentally changed the practice ofmedicine in ways that its developers never foresaw [39]. This type of highlyinteractive and work flow enabled program is creating new collaborative roles forcomputers in complex organizations. The system is able to supervise and monitorcare [38,40], enabling computers to perform many care coordination and documen-tation functions, freeing people to concentrate more fully on interpersonal interac-tions and providing of health care services.

This article reports preliminary results from one of the first projects to applycognitive evaluation techniques to the assessment of the effectiveness of clinicalsystems deployed in a health care practice. A variety of theoretical articles havedescribed models for using computers to support group activities, including linguis-tic models [49], form-based models [13], process models [20], and intelligent agentmodels [30]. Further articles have discussed evaluation of collaborative systems inlaboratory environments [24,26], showing that group interactions are enhanced byincorporating work flow into application systems. Examination of the effect ofcomputerization on social processes in real world settings has been lacking,however. [17,19]. Evaluations of deployed collaborative systems have tended tofocus on the ability of these systems to replace conventional communication mediawithout describing the effects on interpersonal and organizational communication[6,7,15]. Observations of the organizational impact of implementing hospital-basedcomputer systems have indicated that the impact on individual roles and communi-cation patterns can be both significant and unexpected [1–3].

This study applied a global evaluation strategy to the validation of the effective-ness and usability of computer systems in an outpatient practice, together with anassessment of the effects on practice and group interactions within the health careteam [16,21,22,33]. The effects of computerization on the interactions of health careproviders with patients and families whereas also examined, as well as patients’attitudes toward the computer system.

Medicine is characterized by the need for experts in many roles (physician, nurse,etc.) to work collaboratively to perform complex tasks. A patient normally interactswith individuals in many roles during the course of a visit, each requiring a highdegree of specialized training, and having clearly defined responsibilities. Patientcare is thus an ideal domain for investigating the effects of computer-assistedcollaborative systems on complex real-world environments.

Given today’s explosion of knowledge, decision making has become a process ofdistributed cognition in which team members bring their expertise and domainknowledge to the issue at hand, collaborating to arrive at the best possible solutions[29,31,35,42]. Technology has contributed to these processes by providing improvedinformation management, just-in-time decision support, and new means of commu-nication such as electronic mail (e-mail). In a clinical practice, providers in nearlyevery clinical role must communicate with those in every other role to some degreeto meet patient needs. This interdependence of roles favors a highly egalitarian

C. Safran et al. / Artificial Intelligence in Medicine 12 (1998) 137–151 139

pattern of communication. Consistent with this egalitarian pattern, we found thatthe least structured modalities of communication are also the most heavily used:face-to-face, phone, and electronic mail.

Electronic mail was observed to be the preferred mode of communication forbrief messages that are not immediately urgent. Previous studies have documentedthe economic and interactive benefits of electronic mail in co-operation with otherforms of communication [8,10,34,45,47]. This is one of the first studies to documentthe emergence of electronic mail as the dominant and preferred communicationmethod for a wide variety of interactions.

The ability to reach anyone at any time without going through administrative‘red tape’ can be seen as one of the chief benefits of electronic mail. This opennesshas the undesired consequence however, of generating large amounts of e-mail. Wefound that some clinicians are becoming overloaded with more electronic mail thanthey can handle. It is not unusual in the practice studied for a provider to receivemore than 50 electronic mail messages a day. Some clinicians reported receiving asmany as 100 messages on heavy days. Using cognitive evaluation techniques, thisstudy examines the effects of the electronic patient record and e-mail on theinteractions of health care providers, evaluating the changes generated by theintroduction of computer capabilities into the health care team.

2. Background

Boston’s Beth Israel Deaconess Medical Center is served by a highly integratedclinical computing system introduced in the late 1970s [5]. It functions in thecoordination of the flow of information between clinicians, who keep their medicalrecords online, as well as between clinicians and their support environment.

The computer system at the Beth Israel Hospital includes approximately 5000computer terminals throughout every department of the hospital. Each departmentcommunicates via these terminals (as well as through other methods such astelephones and face-to-face contact), so that information is entered directly into thecomputer system and is then instantly available to anyone who requires it. E-mailis also available and heavily utilized (16 000 messages/week), and has become a keymethod of communication among the hospital staff [43,46].

Additional features which provide support to the health care professionalsinclude decision support programs in areas such as electrolyte and acid-baseprogram, information on medications [46], support in the care of patients with HIV[40], computer-based alerts to changes in condition [38], and assistance withdetermination of discharge medications [44]. A MEDLINE literature search pro-gram, PaperChase, is also available and is used frequently, with 1600 searches in a1 week period.

Analyses of components of the systems have been carried out since theirinception and the results have been encouraging in establishing the usefulness of theindividual technologies introduced. The manner in which technology has beenincorporated into everyday practice has been evaluated through studies of fre-


quency of utilization [5,39,43] as well as its effects on clinician’s patient-care decisions and on patient outcomes [38,40,46,41]. The study reported herebroadens the scope of these examinations of technology in health care by investi-gating the impact of computerization on collaborative processes among teammembers.

3. Methods

3.1. Study site

The Beth Israel Deaconess Medical Center in Boston is a 478 bed hospitalaffiliated with Harvard University with approximately 30 000 admissions and200 000 out-patient visits annually. These patients are cared for by 3500 healthcare professionals.

Healthcare Associates (HCA) is an outpatient unit delivering primary care. Itoccupies the sixth floor of the outpatient wing of the Beth Israel Hospital. It isdivided into three suites, or groupings, designated south, central, and north. Eachsuite has its own door, registration desk and waiting area. They lead to intercon-nected areas consisting of examining/interview rooms, conference rooms, workrooms, and practice assistant pods. Each of the three suites includes a conferenceroom, a work room, examining/interview rooms, two pods, and several hallwaystations with terminals. Internal waiting areas provide places for patients to waitthat are more accessible to the health care providers.

The conference and work rooms contain four to six terminals, the pods con-tain two terminals, and each examining room contains one terminal. The practicehas had an electronic patient record since 1991, and clinicians are able to carefor patients without traditional paper records [39]. The terminals are either dedi-cated terminals or consist of a stand-alone personal computer with terminalcapabilities.

3.2. E6aluation methods

Analysis of work patterns within the practice was conducted to identify inter-actions between team members, examining social dynamics of the decision-mak-ing process, group strategies and processes through which decisions are made,peer influences, and organizational (hospital) influences on decision-makingwithin the unit [32]. The methodologies employed were developed at the Centrefor Medical Education, McGill University, and are aimed at assessing the groupprocesses involved in complex medical decision making. Techniques have alsobeen developed for the analysis of the use of advanced computer systems inclinical settings [23,33]. The outcome of this analysis is a model of the interac-tions within the unit, detailing roles and interaction patterns. This interactive


model also provides information as to the roles of the tools provided by thecomputer system, validating their effectiveness in terms of whether team membersemploying them achieve their goals.

The methodologies implemented are based on an ethnographic approach, withthe aim of observing the environment and the roles within it while not disturbingthe processes under investigation [9]. The study began with a work domainanalysis [36,37], in which the objectives, functions, activities, and resources of theteam were determined. Goals and limitations were identified and priorities deter-mined. General functions and activities were then described. The setting in whichthese activities take place and the material resources available provide the physi-cal context for the work domain, and are therefore significant components of theanalysis.

Data was collected over two periods of 2 weeks each, during which keypractitioners were accompanied as they went about their daily activities. Thisgenerated a picture of a typical day in the lives of individuals in the unit. Eachsubject was accompanied for one half day as he or she went about deliveringpatient care. Practice assistants (who assist providers with administrative tasks,direct patients and book appointments, assist with procedures, draw blood sam-ples, answer telephones, etc.) and secretaries at the reception desk were alsoobserved in a less structured manner. The purpose and methods of the studywere explained to each subject. When patients were involved, the provider ex-plained the study to them, including their right to refuse with no repercussions.

Detailed field observations and audio recordings of all interactions were made.Interactions through voice mail and e-mail were included as well [9]. Patient andprovider consent were obtained before audio or video recording. Patient-providerinteractions were videotaped [1,22]. These tapes were then analyzed for the set-ting, i.e. HCA office or telephone, the diagnoses of each patient and the healthcare providers involved in their care, and the amount of time spent by theprovider doing several activities. Semi-structured interviews were conducted andaudiotaped exploring the attitudes of the patients toward the computer and theirproviders’ use of it [11]. By combining a multiplicity of data collection techniquesand sources, we attempted to generate a broad picture of the functioning of theunit [50] providing a model of interactions and group decision-making processeswithin the unit, and an evaluation of the role of the computer system withinthose processes. Data was collected at the Beth Israel Hospital and analyzed atMcGill University.

An activity model was developed based on these observations. The analysiswas conducted with particular attention to the role of technology in supportingpractice in the unit. The work domain, including the physical setting, the individ-uals, and the patterns of work activity were analyzed, and an activity analysisinitiated. Results of the analyses were compared with characterizations of tradi-tional primary care units to assess changes generated by the implementation ofthe computer system.


4. Results

4.1. Communication among clinicians

Interactions among clinicians were analyzed by defining clinical roles, specifyinggoals, tasks, and responsibilities accomplished within each role, and observing thetypes of interactions that occurred among people filling each role. The variety andcomplexity of issues presented by the patient population of HCA require a broadrange of expertise. HCA personnel therefore includes experts in the medical,nursing, mental health, and community resource domains. Within each domain, thelevel of expertise ranges from novice (e.g.: Intern) to specific expert (e.g.: FacultyPhysician, Psychiatrist, Nurse Practitioner, Social Worker). The administrativehierarchy is based on lines of accountability, reflecting level of domain expertise,education, training, and experience required of the various roles.

The provider roles described do not function in isolation but rather as a team.Orasanu and Salas [29] describe a team as not only a group of people, but as agroup with members who are interdependent and coordinated with defined rolesand responsibilities. They receive information from many sources, manage internalresources adaptively, and possess expertise relevant to the tasks involved inachieving the goals of the group. The actions and decisions of the individuals withinthe team occur in the context of the team, the social environment, and the physicalenvironment [16,18,31,35,42]. Communication is a fundamental pathway throughwhich individual roles develop into a functioning team [29] and therefore wasexamined further.

A content analysis was performed on observed communication betweenproviders. No single topic category was seen to account for more than 25% ofcommunication, and six categories each counted for more than 10% (care plan,patient status, team activity, intervention, diagnosis, and administration). Thisdiversity of topics suggests that standard forms such as mail templates willprobably be of limited use. We feel that text templates are best applied toinformation that is already structured, such as patient assessments, care plans, anddischarge plans.

A very small percentage of communication was devoted to evaluation (0.5%).This finding suggests that computer systems for the automatic evaluation of care,while often discussed as a potential application of artificial intelligence technology,may have limited application in an outpatient setting. It is clear that evaluation inthe practice studied is occurring continuously as part of the delivery of care.

The pattern of interactions showed a constant flow of communication, consistentwith the team approach of the unit. This flow is not based on any visible hierarchy,though there is more communication within provider areas. The most strikingobservation about the interactions between the providers of HCA is the egalitarianpattern. Communication centers on the goal of the interaction, with the players,content, and direction being determined by the nature of the expertise required andthe caregiver who possesses it, be that Community Resource Specialist or PracticeDirector. Interactions among providers are based on individual levels and domains


of expertise rather than on hierarchical positions, creating this egalitarian pattern.The communication pattern observed within the team is consistent with earlierstudies that observed egalitarian tendencies in computer-assisted communication[17,48], and with cognitive research demonstrating that efficient communication isa hallmark of experts and expert teams [12,28].

4.2. Integration with clinical practice

Of the sample of 12 providers interviewed, 11 reported finding the computer auseful addition to their practice and an improvement over previous tools. The 12thprovider later modified initially negative comments, stating that the computer’susefulness outweighed its drawbacks. A major advantage of the computer systemobserved during the delivery of patient care is the easy accessibility to informationfrom any terminal. Terminals themselves are easily accessible, located at keylocations such as examining/interview rooms, hallways, conference rooms, workrooms, and secretaries’ desks. This allows providers access to all of it’s the system’sfeatures without tying them to specific locations. This is particularly useful for rolesinvolving coordination of patient flow, such as Clinical Triage Nurses, CommunityResource Specialists, Practice Assistants, and Secretaries, in that they have quickand easy access to the patients’ records and can assess issues based on knowledgeof the patients’ histories. Results of tests and consultation referrals are available,and medication orders and progress notes are easily accessed and verified. Unsched-uled issues can be assessed quickly and efficiently, even during a phone call,through access to the online medical record system (OMR). Appointments can becoordinated since everyone has access to appointment schedules of both patientsand other providers.

Several providers report finding the output of the system to be useful. A popularfeature of the OMR is the prescription reordering and printing, in which prescrip-tions do not have to be re-entered and re-written. Both steps can involve as little asa few key strokes, which is seen as a major advantage over paper methods. It alsofacilitates the maintenance of an updated list of medications in the medical record.A printout of portions of the OMR is also provided to providers prior to thepatients’ appointments. They were seen to rely on it heavily, referring to it duringvisits and making notes on it.

Many clinical areas outside of the primary care practice do not utilize the on-linemedical record for complete charting. This affects the inclusiveness of OMR andcreates frustration for the primary care providers when looking for records ofdepartments that are not online. All providers at the hospital have computer accessto results of tests ordered by other departments.

4.3. Effects on patient-pro6ider interaction

The computer system facilitates several components of the patient-providerinteraction. Easier access to information releases providers to attend to the patientand increases the resources and information available to do so. Examples include


ordering medications, which no longer requires a hand-written prescription, thereadily available Physician’s Desk Reference, a well-known reference source forphysicians’ practice, and the Formulary, a list of all medications provided by theBeth Israel Hospital pharmacy. Their accessibility facilitates providing patientswith information and clarifying unfamiliar medications that patients ask about,as well as maintaining an updated medication list, checking other appointmentsthat the patient has booked or that a provider of interest has available, sendingreferrals and consults, and maintaining a readily available problem list. Thesystem also provides teaching tools, such as the ability to print out informationdescribing any medication in the Formulary, while the patient is available andwithout having to look through files, shelves, and cabinets.

Whenever any provider comes into contact with any patient, they have accessto the medical record as well as planned appointments. This assures that theproviders are up-to-date with the patients’ care and gives patients a sense ofbeing known, as any provider will have an awareness of the issues of importanceto them. This access is extended to providers who are outside the hospital,allowing them to access the system from home, other offices, and other institu-tions. This allows providers to prepare for appointments ahead of time, tofollow-up on expected results quickly, and to remain accessible and in communi-cation while away from the unit.

Initial observations show that the presence of the computer does affect theprovider/patient interactions in subtle ways. The necessity of ‘interacting’ withthe terminal is distracting, taking attention away from the patient. Providers wereobserved to have compensated for this by reviewing patient material prior to theappointments and by using the OMR printout provided rather than the OMRitself while actually with the patient. The extent of the influence on the interac-tion relates very strongly to usability. The more interaction required by thesystem, the more distracting it is and the more likely providers are to resort tomore traditional, familiar modes of functioning, i.e. paper records. This might beremedied by having the patients looking at the screen as well as the providers,creating a three-way interaction that might be more comfortable for theproviders as well as for the patients.

Patient interviews showed no relationship between the amount of timeproviders spent with the computer and patient satisfaction. In fact, patients wereuniformly positive about the system, though one patient reported that she hadinitially been leery of it. This finding is consistent with a recent study showing ahigh degree of acceptance of patient-provider electronic mail [27], which is usedat HCA by hospital employees who are also patients. Features noted by patientsincluded improved access and ease of prescription writing for the provider. Therewere no reports by patients of the computer interfering with patient-providerinteractions. The major concern expressed was that of confidentiality.

Voice mail provides similar capabilities as electronic mail, but listening is moretime-consuming than scanning a written note and is more difficult if not impossi-ble to screen. E-mail is also more likely to be used than voice mail because of


the awareness, as reported in interviews, that providers will be alerted to thepresence of e-mail messages each time they log onto their terminals and canquickly flip through these messages. Voice mail is reported to be less noticeableand picking up messages was observed to require more thought and attention.

Providers spend proportionally more time actually talking with the patientduring a phone call than during an office visit, with MDs using the OMR asbackup during a phone call more than NPs. Providers use the computer morewhen on the phone, and use the printout more during an office visit.

4.4. Alerts and reminders

Alerts and reminders are a feature of OMR which prompts providers that aparticular intervention might be indicated for a particular patient. They appearautomatically and are a major advantage of on-line medical records in that theyprovide just-in-time triggers, again reducing the cognitive load required of theprovider. Reminders differ from alerts only in that the messages in reminders arenot important enough to interrupt workflow, whereas the information in an alertmessage may require urgent action. A reminder might indicate that the clinicianhas not signed a progress note after a certain amount of time, while an alertmight suggest that a provider should immediately change the dose of an antibi-otic because of a change in a patient’s renal function [38].

Of the providers observed, most appreciated the presence of alerts and re-minders and checked them regularly. Another perspective, seen more in expertpractitioners, saw them as annoying in that they were unnecessary. It is possiblethat the expert has a sufficient mastery of the area that such reminders are notrequired and therefore serve only as distractions, while the provider at an inter-mediate level of expertise would appreciate the support. However, this expertperception is dissonant with observed behavior in a controlled clinical trial ofalerts and reminders [40,41], in that providers at all levels of expertise foundgreat benefit in computer generated suggestions.

The availability of just-in-time reminders and alerts together with theother decision support systems online represent a significant difference from moretraditional methods of the delivery of care. Although at times perceived asdistracting, these tools support the reasoning of the expert provider as well asreducing the memory load. Without reminders, the provider must remember andbe alert to all the information related to each patient. This is a significantdemand on attention and on the memory of a traditional provider. Allowing theuser to choose the level of alerts and reminders, adapting to their own level ofexpertise, might reduce the interference in expert reasoning processes. Access toreference materials during the patient visit also supports decision making. In atraditional unit it is necessary to locate references. Common ones are oftenavailable in a central location, but this does not match the efficiency of on-lineavailability.


4.5. Collaboration

Collaboration is one of the tenets of good patient care in a practice like HCA.The level of expertise of the providers is such that they practice independently, withmost communication being either to inform or to consult. This reflects an efficientuse of interactions, with the expertise of each provider being at a level such thatindependent practice can be supported. Roles and responsibilities are definedsufficiently clearly that each provider provides care required by the patient and cancommunicate that care process using the computer system, so that comprehensivecare is still provided. Consultation was observed to be most frequent betweenspecific experts and generic experts. Nurse practitioners consult with preceptors andprimary care physicians (PCP) regarding medical decisions. Clinical nurses consultwith nurse practitioners and PCP regarding decisions requested by patients askingfor advice or information. Residents consult with preceptors and physicians fre-quently.

The nature of the expertise necessary to deliver health care is beyond the abilityof one individual to master. Decision making is therefore distributed among themembers of the team. In a study of an ICU setting [31], it was found that eachmember of the health care team had specific responsibilities, and that eachcomplemented the other. This is observed in this sample as well. The involvementof the computer in this process is facilitated by its ready availability throughoutHCA as well as from outside the hospital. When the team is discussing an issue, thecomputer is at the location and is included as a resource.

5. Discussion

One of the challenges in the design of computer systems to assist health careproviders is how to support collaboration while not requiring that people meetface-to-face. Our evaluation has indicated that the hospital’s electronic patientrecord and e-mail system represent successful applications of technology for thispurpose. However, we have found that the introduction of these new technologieschanges the clinical environment in both positive and negative ways. Positivebenefits include improving communication, collaboration, and access to informa-tion to support decision-making. Negative factors include the potential for over-loading clinicians with unwanted or unnecessary communications and perceivedisolation of providers.

A major difference observed between the HCA and more traditional primary careunits is the accessibility of the patient record. This is in contrast with a traditionalunit in which all information is in a paper chart which is usually stored in a medicalrecords department. If access to the chart is required, it must be requested andretrieved from this central location. This can take as little as a few minutes or aslong as a day. Because clinical records are so accessible in HCA, they are alwaysconsulted when discussing an issue with a patient or provider, with no consider-ation of time or effort required to gain access to a paper chart. Every time a patient


calls with a question, the OMR is accessed and an informed reply provided. Thisaccessibility extends to locations outside the hospital, allowing providers to monitortheir patients even when not physically in the building. Without computers, thisrequires telephone contact, which can involve delays.

The nature of data entry in a computer system allows for more efficient updatingof records, such as problem lists and prescription lists. They do not have to berewritten, or crossed off when no longer applicable. Also, computers can simplyprint out the contents of the record. This is particularly useful in the area ofmedication re-ordering. With a computer system, producing a paper prescriptionfor the patient to take to the pharmacy requires a few keystrokes. In addition, theprescription is legible, reducing the risk of error. In a traditional system, eachmedication must be re-written each time the prescription must be renewed. For thisreason, this feature is one of the most popular of the OMR.

In addition to the traditional telephone, voice mail, pager, and meeting, clinicianscommunicate using e-mail and the electronic patient record. The electronic patientrecord has become a means of communication in that the observations, plans, andinterventions of other providers are readily available. If an entry is urgent orotherwise important, it is sent via e-mail rather than the electronic patient record.The efficiency of e-mail and its ability to convey detailed information in a rapidmanner has facilitated the exchange of information between providers. E-mail wasboth observed and reported by providers to be a major method of communication.

Voice mail provides similar capabilities as electronic mail, but listening is moretime-consuming than scanning a written note and is more difficult if not impossibleto screen. E-mail is also more likely to be used than voice mail because of theawareness, as reported in interviews, that providers will be alerted to the presenceof e-mail messages each time they log onto their terminals and can quickly flipthrough e-mail messages. Voice mail is reported to be less noticeable and picking upmessages was observed to require more thought and attention.

The large volumes of e-mail observed (up to 100 messages per provider per day)might appear to some degree a sign of a successful application of technology.People use the e-mail system extensively because they find it superior to othermodes of communication for certain types of messages. Individuals might exchangeseveral electronic messages in a day even though they are located in offices a fewyards from each other. Using e-mail rather than the phone or a face-to-face meetingin the hall allows each party to attend to the communication when it is mostconvenient, which can significantly improve efficiency. We feel that the difficultiesproviders face is not the volume of mail but rather the appropriateness andrelevance of the content of messages. We believe most providers would welcome asystem where the messages are brief, to the point, delivered to the appropriateindividuals, and contain links to the additional information needed for the recipientto take whatever actions are required. We are therefore focusing on improving thecontent of communication by incorporating multimedia objects, providing Internetaccess, and allowing documents and data to be attached.

These capabilities are allowing computers to assume a new role in complex healthorganizations. Earlier studies [14] have described the impact that technology has


had in changing human roles from an active system manipulator to a systemsupervisor or monitor. Modern data processing systems, however, need very littlehuman supervision and are able to take on roles within a project team. With thereduced need to supervise and monitor equipment, people are able to concentratemore on interpersonal interactions and providing of services.

An example of this is the use of e-mail, which now allows a computer system toreplace the mail trucks and runners that in an earlier day were indispensable to thefunctioning of a large complex organization. We may conceptualize this change bysaying that a computer has replaced people in performing the ‘letter carrier’ rolewithin the organization.

When the computer takes on the letter carrier role, the process changes, and withit, the levels of expectation. Messages are now delivered instantaneously andextremely reliably. People have begun to expect a response within the same day,often sooner, and are annoyed if they do not receive it. E-mail is often the fastestmedium for getting a response, faster than scheduling a face-to-face meeting andfaster than leaving a phone message. By virtue of technology, mail has changedfrom a means of communicating over distances and creating a written record to thefavored way of communicating brief messages that require a quick response.

E-mail as it is currently provided, however, uses only a small fraction of thecapabilities of a computer. As long as the computer system’s functions are limitedto the delivery of mail in the form that it is received, the computer is performing anadministrative support role, and can not truly be described as collaborating in thework process.

Computers for administrative support must achieve high standards of quality,often higher than would be expected of a person in the same role. Computers areeffective as providers of e-mail, for example, because they rarely lose a message anddeliver mail much faster than the post office. Collaboration places the additionalrequirement on a computer system that it functions in a way that enhances thecapabilities of the people on the work team, just as would be expected of a humancollaborator. This places enormous demands on the user interface, because it mustnot only be easy and effective to use, but must also anticipate the kinds of tasksthat users are likely to want to perform [4,25].

The bridge to collaboration is crossed, we feel, when the computer begins toprocess the contents of the communication. A key capability is seen in automaticalert and reminder programs—programs that send a message to a clinician aboutsome event or workflow issue that needs the clinicians attention. These programscross an implied social barrier by initiating an event based on information that therecipient of the reminder or alert may not be aware of. They carry the implicationthat the determination of the decision to display the alert is sufficiently authorita-tive to demand the recipient’s attention.

Electronic patient records and health information systems that include e-mail canchange the practice of medicine. Although such systems can improve collaborativecare, they can also contribute to information overload. In the future it will beimportant to design clinical systems that incorporate these work-flow consider-ations.


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Electronic communication and collaboration in a health care practice