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Understanding the context and nuances of clinical performance at the front-line can provide valuable insights into why the effects of Health Information Technology implementation might differ across sites. It also helps to inform the design of systems that support performance flexibility as clinicians respond to the changing demands of the clinical environment. This study explored the use of an electronic result acknowledgement (eRA) system by physicians at two Emergency Departments (EDs) at Australian metropolitan teaching hospitals to understand how electronic result acknowledgement is managed differently in response to varying environmental demands. Semi-structured, in-depth interviews relating to physician electronic test result acknowledgement processes were conducted with 21 emergency physicians. Physician use of the eRA system differed in four aspects: i) responsibility (i.e. who acknowledges test results); ii) types of tests acknowledged; iii) coordination and synchronisation (i.e. when acknowledgement occurred); and iv) documentation of follow-up actions.

Objective: To examine the impact of an electronic Results Acknowledgement (eRA) system on emergency physicians' test result management work processes and the time taken to acknowledge microbiology and radiology test results for patients discharged from an Emergency Department (ED)., Methods: The impact of the eRA system was assessed in an Australian ED using: a) semi-structured interviews with senior emergency physicians; and b) a time and motion direct observational study of senior emergency physicians completing test acknowledgment pre and post the implementation of the eRA system., Results: The eRA system led to changes in the way results and actions were collated, stored, documented and communicated. Although there was a non-significant increase in the average time taken to acknowledge results in the post period, most types of acknowledgements (other than simple acknowledgements) took less time to complete. The number of acknowledgements where physicians sought additional information from the Electronic Medical Record (EMR) rose from 12% pre to 20% post implementation of eRA., Conclusions: Given that the type of results are unlikely to have changed significantly across the pre and post implementation periods, the increase in the time physicians spent accessing additional clinical information in the post period likely reflects the greater access to clinical information provided by the integrated electronic system. Easier access to clinical information may improve clinical decision making and enhance the quality of patient care. For instance, in situations where a senior clinician, not initially involved in the care process, is required to deal with the follow-up of non-normal results., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: (1) to describe Emergency Department (ED) physicians' and nurses' perceptions about the sequence of work related to patient management with use of an integrated Emergency Department Information System (EDIS), and (2) to measure changes in the sequence of clinician access to patient information., Methods: A mixed method study was conducted in four metropolitan EDs. Each used the same EDIS which is a module of the hospitals' enterprise-wide clinical information system composed of many components of an electronic medical record. This enabled access to clinical and management information relating to patients attending all hospitals in the region. Phase one - data were collected from ED physicians and nurses (n=97) by 69 in-depth interviews, five focus groups (28 participants), and 26 h of observations. Phase two - physicians (n=34) in one ED were observed over 2 weeks. Data included whether and what type of information was accessed from the EDIS prior to first examination of the patient., Results: Clinicians reported, and phase 2 observations confirmed, that the integrated EDIS led to changes to the order of information access, which held implications for when tests were ordered and results accessed. Most physicians accessed patient information using EDIS prior to taking the patients' first medical history (77/116; 66.4%, 95% CI: 57.8-75.0%). Previous discharge summaries (74%) and past test results (61%) were most frequently accessed and junior doctors were more likely to access electronic past history information than their senior colleagues (χ(2)=20.717, d.f.=1, p<0.001)., Conclusions: The integrated EDIS created new ways of working for ED clinicians. Such changes could hold positive implications for: time taken to reach a diagnosis and deliver treatments; length of stay; patient outcomes and experiences., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Despite well-articulated benefits, the introduction of Nurse Practitioners (NPs) in Australia has been slow. Poorly defined nomenclature relating to advanced practice roles in nursing and variations in such roles both across Australia and worldwide have resulted in confusion and uncertainty regarding the functions and roles of NPs. Qualitative studies focussing on the perceived impact on the care settings into which NPs are introduced are scarce, but are valuable in providing a complete contextual account of NPs in care delivery settings. This study aimed to investigate the perceived impact of the NP on the delivery of care in the ED by senior doctors, nurses, and NPs. Results will facilitate adoption and best use of this human resource innovation., Methods: A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior doctors (staff specialists and ED directors) and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the impact of the NP role on the ED. Member checking of results was conducted by revisiting the sites to clarify findings with participants and further explore emergent themes., Results: The impact of the NP role was perceived differently by different groups of participants. Whilst NPs were observed to deliver few quantitative improvements to ED functioning from the perspective of ED directors, NPs believed that they assisted doctors in managing the increasing subacute presentations to the contemporary ED. NPs also believed they embraced a preventative paradigm of care which addressed the long term priorities of chronic disease prevention and cost containment in the broader healthcare environment. The ambiguous position of the NP role, which crosses the gap between nursing and medicine, emerged and resulted in a duality of NP governance., Conclusions: Interpretation of the NPs' role occurred through different frames of reference. This has implications for the development of the NP role in the ED. Collaboration and dialogue between various stakeholders, such as ED doctors and senior nursing management is required.

Study Objective: We identify and describe emergency physicians' and nurses' perceptions of the effect of an integrated emergency department (ED) information system on the quality of care delivered in the ED., Methods: A qualitative study was conducted in 4 urban EDs, with each site using the same ED information system. Participants (n=97) were physicians and nurses with data collected by 69 detailed interviews, 5 focus groups (28 participants), and 26 hours of structured observations., Results: Results revealed new perspectives on how an integrated ED information system was perceived to affect incentives for use, awareness of colleagues' activities, and workflow. A key incentive was related to the positive effect of the ED information system on clinical decisionmaking because of improved and quicker access to patient-specific and knowledge-base information compared with the previous stand-alone ED information system. Synchronous access to patient data was perceived to lead to enhanced awareness by individual physicians and nurses of what others were doing within and outside the ED, which participants claimed contributed to improved care coordination, communication, clinical documentation, and the consultation process. There was difficulty incorporating the use of the ED information system with clinicians' work, particularly in relation to increased task complexity; duplicate documentation, and computer issues related to system usability, hardware, and individuals' computer skills and knowledge., Conclusion: Physicians and nurses perceived that the integrated ED information system contributed to improvements in the delivery of patient care, enabling faster and better-informed decisionmaking and specialty consultations. The challenge of electronic clinical documentation and balancing data entry demands with system benefits necessitates that new methods of data capture, suited to busy clinical environments, be developed., (Copyright © 2012. Published by Mosby, Inc.)

Background: The disruptive potential of the Nurse Practitioner (NP) is evident in their ability to offer services traditionally provided by primary care practitioners and their provision of a health promotion model of care in response to changing health trends. No study has qualitatively investigated the role of the Emergency NP in Australia, nor the impact of Information and Communication Technology (ICT) on this disruptive workforce innovation. This study aimed to investigate ways in which Nurse Practitioners (NP) have incorporated the use of ICT as a mechanism to support their new clinical role within Emergency Departments., Methods: A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior physicians and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the ED nurse practitioner role and the influences of ICT upon the role. Member checking of results was achieved by revisiting the sites to clarify findings with participants and further explore emergent themes., Results: The role of the ENP was distinguished from those of Emergency nurses and physicians by two elements: advanced practice and holistic care, respectively. ICT supported the advanced practice dimension of the NP role in two ways: availability and completeness of electronic patient information enhanced timeliness and quality of diagnostic and therapeutic decision-making, expediting patient access to appropriate care. The ubiquity of patient data sourced from a central database supported and improved quality of communication between health professionals within and across sites, with wider diffusion of the Electronic Medical Record holding the potential to further facilitate team-based, holistic care., Conclusions: ICT is a facilitator through which the disruptive impact of NPs can be extended. However, integration of ICT into work practices without detracting from provider-patient interaction is crucial to ensure utilisation of such interventions and realisation of potential benefits.

Follow-up of abnormal test results for discharged Emergency Department (ED) patients is a critical safety issue. This study aimed to explore ED physicians' perceptions, practices, and suggestions for improvements of test result follow-up when using an electronic provider order entry system to order all laboratory and radiology tests and view results. Interviews were conducted with seven ED physicians and one clinical information system support person. Interviews were analyzed to elicit key concepts relating to physicians' perceptions of test result follow-up and how the process could be improved. Results described the current electronic test result follow-up system with two paper-based manual back-up systems for microbiology and radiology results. The key issues for physicians were: responsibility for test follow-up; the unique ED environment and time pressures, and the role of the family physician in test result follow-up. The key suggestion for improvement was a complete integrated electronic information system with on-line result endorsement. The study highlighted the complexity of the test result follow-up process and the importance of engaging clinicians in devising solutions for improvements.

Increases in attendance rates at emergency departments (EDs) have prompted concerns regarding inappropriate utilisation. Factors instigating patient ED attendance were examined using a cross sectional survey of 522 patients presenting to the ED of a rural hospital in Australia, during a 1-week period. The results highlighted the importance of the rural hospital ED as an additional and alternate service to existing primary care facilities, particularly outside of business hours. The findings indicated that although patients' perception of an emergency does not necessarily correspond with clinical interpretations, the primary factors prompting attendance, including general practitioner unavailability, referrals and special service needs, suggest that, from a patients' perspective, the majority of presentations to the ED are justified.