Citation: Aronson, T., Oertle, S. & Piscotty, R. (2021). Key characteristics of a successful EHR-supported e-handoff tool: A systematic review. Online Journal of Nursing Informatics (OJNI), 25(1), https://www.himss.org/resources/online-journal-nursing-informatics
Communication failures in health care are the leading cause of sentinel events costing health care organizations about $1.7 billion and more than 250,000 patients their lives each year (Makary & Daniel, 2016; Hoffman & Bergquist, 2015). One of the main reasons for communication failures is the handoff report process between health care providers. This exchange of information does not typically involve information sourced from the electronic health record (EHR) nor does it follow a standardized structure (Zou & Zhang, 2016). To address these issues, some EHR companies have begun to embed handoff tools within their software. Even though these tools are becoming more prevalent in EHRs, they unfortunately are often not used by health care personnel.
A systematic review was conducted to further investigate what characteristics of implemented EHR-supported report tools contributed to their successful adoption and use. Articles for the review were sourced from CINAHL, Cochrane Library, EBSCOhost, Health Source Nursing, Medline, and Science Direct. The authors also performed a hand search and an ancestry search to augment the findings. Twenty articles met inclusion criteria for the review and highlighted several key themes that were prevalent among successfully adopted EHR-based e-handoff tools. The findings include standardization, customization, user involvement, and the presentation of a comprehensive overview. These handoff tools were shown to reduce communication failures and provide a more comprehensive, expedited handoff report.
A staff handoff report is the exchange of information and shifting of responsibility during the transfer of care for the purpose of providing a concise overview of a patient’s case (Zou & Zhang, 2016). Traditionally, this occurs at the end of the outgoing provider’s shift with a verbal recounting of patient information and events during the shift to the oncoming staff (Flemming et al., 2014). Ideally, this should be a succinct discussion, but studies have indicated that the handoff process is informal, unstructured and fallible, thus making it prone to errors (Zou & Zhang, 2016). These errors are further compounded by multiple factors, mainly caused by the verbal communication medium, including a “telephone game” effect during which the information provided in the report becomes distorted from multiple transmissions (Zou & Zhang, 2016). Other factors that further compound communication errors include the oncoming staff focusing on dictating the report contents rather than internalizing the information due to the verbal nature of the report and an overall lack of questions and clarification during the report as the report process can be rushed (Flemming et al., 2014). All of these elements result in omissions and misinterpretations of vital information, thus potentially compromising patient care and introducing the possibility of significant errors (Alghenaimi, 2012).
Medical errors as a whole, including those caused by communication mishaps, are a leading cause of sentinel events, costing health care organizations about $1.7 billion and more than 250,000 patients their lives every single year (Makary & Daniel, 2016; Hoffman & Bergquist, 2015). To combat the inefficiencies and errors caused by a handoff report, some electronic health record (EHR) companies have begun to develop and implement standardized report tools in their EHRs ("Electronic Health Record Implementation – I-PASS Institute", 2018). Historically, EHRs have provided staff a repository to input clinical information and document care but, after being entered, the information is not always used for handoff reports (Flemming et al., 2014). EHR report tools seek to remedy this shortcoming by extracting pertinent clinical data and organizing it into a structured report for the oncoming staff (Arsoniadis et al., 2017; Flemming et al., 2014). Although these tools are becoming more prevalent and have the potential to aid provider communication, they have yet to become a true staple in the handoff process as, even when they are available, they are often not used (Staggers et al., 2012).
The current dearth of in-built EHR report applications and staff’s continued use of traditional handoff reports perpetuate communication errors, pointing to the need of improved handoff reporting methods including robust EHR handoff tools (Guilbeault et al., 2015). While the rationales underlying the benefits of improved communication are apparent, the reason EHR handoff tools are being adopted in current practice as a tool to aid staff handoff are not. The aim of this review is to understand what characteristics of successfully implemented EHR report tools contributed to their adoption and use.
A systematic search and review of evidence was conducted in line with the research aim of identifying published studies on the use of EHR-supported health care handoff reporting tools and their use in promoting safe, structured handoff reports. The research review was conducted using CINAHL, Cochrane Library, EBSCOhost, Health Source Nursing, Medline, and Science Direct. Handsearching of other relevant resource forms, such as websites, dissertations and white papers, was performed by the authors to augment the findings. To further bolster the findings, an ancestry search of all resources found was conducted. The literature search was completed in February 2019. To find pertinent publications from electronic databases related to the search criteria, the keywords “EHR” and “handoff” were searched in all databases. The search of literature was limited with the following initial inclusion criteria: published in English, peer-reviewed, academic journals, and a publication date between 2009 to 2019. Due to the rapid development of technology, the search was limited to the last 10 years to ensure current information.
Based on the above search criteria, 38 articles were identified from the database search and six from the hand search for a total of 44 results. These articles were screened for duplicates, with 34 unique articles being included after the title screening. Article titles were screened and those that did not relate directly to the research aim, did not utilize the EHR, did not use an electronic form of handoff, or were focused on technical aspects of EHRs were removed. This resulted in 26 remaining articles qualifying for a full text review. A total of 20 articles related to the research aim were deemed appropriate for inclusion from the full text review and were included in the final review. The selected articles addressed health care handoffs with a focus on using the EHR and an electronic tool to enhance the handoff. A PRISMA diagram documenting the search, as well as further details about inclusion and exclusion criteria, is presented in Figure 1.
Figure 1: PRISMA diagram of search process
These articles were also rated based on Melnyk and Fineout-Overholt’s hierarchy of evidence to determine the overall strength of the evidence (2011). A summary of the ranking and article information is presented in Table 1.
Table 1: Article information and Level of Evidence (LOE)
Twenty articles related to EHR integration with staff handoff were retrieved during the search period. All 20 were published in journals or were part of dissertations. Table 1 contains a summary of these results to provide a comprehensive overview and illustration for better understanding. These studies were predominantly from the United States, with additional studies from Germany, Australia, Canada, Taiwan and the United Kingdom. Most study participants were nurses or physicians working in clinical settings. Overall, the quality of the evidence strength was moderate, with a mix of studies consisting of three randomized controlled trials, 10 quasi-experimental studies, one cohort study without randomization, and six descriptive cross-sectional studies, all with the aim of studying handoffs and the use of EHR report tools. As mentioned, the reviewed studies varied in their design, but the majority were quasi-experimental studies. Most studies used surveys/questionnaires pre- and post-implementation of the EHR-based tool to obtain user feedback regarding their perceived effectiveness in communication and workflow. These self-reported measures proved to be invaluable in the development of e-handoff tools and their success after implementation.
The need for an effective electronic EHR-supported handoff tool is universal and required by multiple disciplines (e.g. students, nursing, physicians, etc.) in an array of settings all over the world. This is because the health care field demands high reliability to avoid mistakes with potentially fatal consequences. Therefore, maintaining a proactive, preventative approach to safety is imperative. By using e-handoff tools, communication errors can be circumvented. However, to avoid these errors, several key components must be included in an e-handoff implementation.
User involvement in design. User involvement during the design and implementation process was a critical component identified through the literature review. One source stated, “The involvement of clinicians is essential to developing a sustainable electronic handover system” (Brebner et al., 2011, p. 94). A large majority of the articles mentioned provider committees and meetings with system users to obtain feedback and input on the development of the e-handoff tools. If developed correctly, the e-handoff can automate workflow and therefore streamline processes (Cheng et al., 2017). If a poorly designed e-handoff was implemented, users were not satisfied and claimed the system did not match the work processes (Staggers et al., 2011). Simply having a usable EHR-based handoff tool is not enough, however. An organization must also take the time to slowly introduce tools to its users. Authors of one study designated unit champions to not only educate staff about the changes to come, but to also gather feedback from the end users (Eberhardt, 2014). Using champions in this fashion can affect how team members receive the newly implemented changes.
Eberhardt noted, “The nursing staff, especially on the medical-surgical units, received the note positively and adopted the change in practice” (2014, p. 19). Authors of another study formed an interdisciplinary safety council to develop an evidence-based handoff module that demonstrated rapid adoption after implementation (LaGrone et al., 2016). A welcoming attitude can mean better compliance rates and staff embracing the change instead of being opposed to new implementations. Other suggested strategies for user involvement included staff engagement in additional electronic tools, process mapping, and training sessions (Chapman, 2016). Giving health care providers the support they need to feel competent and confident using IT tools can positively influence staff satisfaction with the newly implemented tools (Chapman, 2016). By involving staff in the design of EHR report tools, user satisfaction and adoption were greatly improved.
Comprehensiveness of information. The next major trend observed within the literature involves the ability of a successful e-handoff application to provide a comprehensive overview while limiting too much information. Only clinically relevant data should be incorporated into an EHR-based handoff tool so that the process remains efficient and time is not wasted on irrelevant information (Raval et al., 2015). An EHR system contains more information than a health care provider can process; therefore, developers must be careful and selective about what data is included in the handoff report. Currently, staff rely on each other for subjective information that cannot be found in the EHR or that is not easily accessible, thereby reducing compliance with e-handoff forms and EHR system use in general (Flemming et al., 2014). The information exchanged between providers was described as “less rich and more consolidated with fewer details compared to items of the patient record” (Flemming et al., 2014, p. 173). Authors of one study concluded that an optimal handoff module would have the ability to exchange information with the EHR while enabling a degree of independence to allow for a more sophisticated functionality and candid information exchange (Nabors et al., 2016). This finding mimicked those described earlier in which nurses felt the standardized templates were too “rigid” (Staggers et al., 2011, p. 217). Feedback from the same group of nurses expressed their need for information other than the typical data pulled from the EHR and placed in the summary report (Staggers et al., 2011). For example, instead of being provided with only the most recent set of a patient’s vital signs, nurses wanted to see vital signs trended within the last 24 hours (Staggers et al., 2011). By providing staff with a comprehensive report that includes all relevant objective and subjective information, staff can rely on the EHR for a more complete report.
Standardization in structure. By definition, standardization is making something conform to a standard (Google Dictionary, 2019). As discussed above, health care provider handoff reports have been known to be compromised and omit key pieces of information, resulting in potential harm to patients (Zou and Zhang, 2016). Providing health care workers with a standardized format for handoff reports guides the providers in giving a more inclusive handoff to the oncoming shift and allows for the receiving provider to be easily alerted if information is missing (Donnelly et al., 2012). When this standard template is then integrated into an EHR, the handoff report becomes much more comprehensive and can give staff the full picture of a patient’s condition. Information contained within an e-handoff tool may include demographic data, hospital location, medications, laboratory values, and the most recent vital signs (Cheng et al., 2017). Users had the option of entering free text under four different headings: summary, situational awareness/contingency, important meds/labs, and a to-do list (Cheng et al., 2017). In addition, this e-tool had built in automatically refreshing links, which provided the ability to pull important data elements from various sections of the patient’s record (Cheng et al., 2017). Some authors in other studies noted that limiting free text was a positive contribution in regard to maintaining a standard format. In a separate e-tool, developers limited custom free text fields and manual entry of additional information, which was not retained as part of the permanent EHR, preventing errors and false data (Raval et al., 2015). The authors stated, “The accuracy of the EHR-based list comes from [it] being generated directly from the EHR itself” (Raval et al., 2015, p. 8).
Standardization implemented from within the EHR provides accurate patient data, which in turn enhances safety and quality of care while reducing variability among handoffs between health care providers (Cheng et al., 2017). Another benefit to implementing a standardized electronic form is the time it saves over a hand-written report. According to the authors of one study, having a standardized form cut the reporting time in half (Lee et al., 2013). Report standardization not only enhances communication between health care providers but has also been proven to improve communications between providers and patients. One American emergency department (ED) initiated an electronic template to improve continuity of care after discharge; the template proved to be a useful method for handoffs between the ED provider, the patient, and the patient’s primary care provider (). Another ED found that implementing a standardized handoff report increased bed flow efficiency and decreased the time patients were held in the department until they were transferred to their inpatient floor, a process known as ‘boarding’ (). Use of a standardized format aids communication by providing an expectation of what information will be provided in a handoff report, thus allowing for quicker and more complete handoffs.
End-user customizability. Although creating a standard process has been proven to be beneficial in more than one way, nurses felt the standardized patient summary tools included in some EHRs were too “rigid” and did not meet their handoff needs (Staggers et al., 2011, p. 217). In some instances, restrictive EHR-supported handoff applications has even led to an omission of critical information by nurses (Collins et al., 2011). To rectify this rigidity, EHR companies are recommended to provide ways for users to customize the handoff report. To see an e-handoff tool as useful, some health care providers wanted the ability to tailor the information presented to them and deemed this functionality as a critical component (Staggers et al., 2011). These users felt that the summary reports generated within the EHR were too “generic” and sometimes contained unnecessary information for the situation (Staggers et al., 2011, p. 217). For example, if a nurse had been caring for the same patient for two consecutive shifts, the nurse did not find the general patient information (e.g. age, diagnosis, and demographics) particularly useful and only wanted information regarding changes since the last time they cared for that patient (Staggers et al., 2011).
Authors conducting a study in the neonatal intensive care unit (NICU) found that when the functionality of an e-handoff report was designed specifically for that discipline’s workflow, provider satisfaction improved and efficiency increased, leading to greater acceptance among the staff (Palma, et al., 2011). A good example of this is Freitag’s handoff tool, which incorporated patient specific safety concerns (such as fall risk) and reflected protocols relevant to the patient’s condition (Freitag & Carroll, 2011). To further improve user customizability in handoffs, Staggers et al. (2012) concluded that for an e-handoff form to meet the cognitive support needs set forth by nurses, it must meet the same utility and cultural function as a paper handoff. A successful EHR-based tool must maintain a balance of standardization and customization. If an e-handoff form contained too much information, users were less likely to use it, thus increasing the risk of compromising the handoff report (Flemming et al., 2014). When having some customizability in handoff report tools, staff were able to organize information in a way that improved their personal understanding while still allowing all required information to be discussed.
Additional themes. In addition to the main themes previously discussed, a few more trends are worth mentioning. One is the visual presentation of the e-handoff form. Several studies were done on the evaluation of how the information was presented, paying close attention to list format as opposed to grid format (Hübner & Przysucha, 2017). Authors Hübner & Przysucha performed a cross-over study involving 30 nursing students that demonstrated less mental demand was needed for a handoff report when it was presented in a cognitive map (grid format) versus the standard list-based style (2017). By presenting handoff information in a focused pictorial style, detailed information from the EHR is formatted into relevant content by the outgoing provider (Flemming et al., 2015). The oncoming provider then can gain an overview of the patient case in a relatively short amount of time (Flemming et al., 2015).
Mobility was also a factor in the adaptation of an e-handoff application. Nurses found it too taxing to access the electronic form due to the requirement of have to log on to a computer (Staggers et al., 2011). Even when computers were available within the patient room or had access to a computer on wheels, nurses still found it to be too strenuous and time-consuming (Staggers et al., 2011). Formatting the e-handoff for access on a mobile device may help correct this issue if the device can be wearable or fit in the nurses’ pocket (Staggers et al., 2011). Lastly, nurses also expressed concerns that information would not be retained as well if typed into a report versus being hand-written (Staggers et al., 2011). Equipping the mobile device with stylus-type functionality could be a solution to this concern.
Multiple characteristics of EHR-based handoff tools contributed to their successful adoption and use, including user involvement in design, the presentation of comprehensive information, standardization of the report, end-user customization, the aesthetic of the report tool, and report tool mobility. When these characteristics were used in conjunction, they contributed to a positive report experience and improved communication efficacy. This improved communication efficacy, not only reducing errors resulting from miscommunication but also having a rippling impact on other care areas. One study found that using an e-handoff report decreased boarding times in the ED while another study found that using electronic tools improved the continuity of care by improving information flow between hospital staff and primary care providers (Potts, et al., 2018; Watkins & Patrician, 2014). By using these tools, staff also reported a greater level of satisfaction with the report process and were also able to significantly expedite the report process, thus leaving more time for direct patient care (Palma, et al., 2011; Eberhardt, 2014; Lee, et al., 2013).
When creating, adopting, and implementing EHR-supported handoff report tools, organizations can use the aforementioned characteristics to support them to be successfully used and thus for the benefits of its use to be seen. Of the characteristics identified, “user involvement in design” and “comprehensiveness of information” were the two most crucial to successful implementation and what organizations should focus on first.Staff who have years of experience performing and receiving a handoff report will want the report to be comprehensive enough for them to not need other tools, structured so it is easy to use, and customizable for any things they wish to personalize.
Different staff (e.g. those in pediatric units versus intensive care units) will likely require different information for their handoff reports to be comprehensive and thus, while involving staff is beneficial, the staff must be from diverse areas for widespread adoption. The specialized staff will be able to provide input on which pieces of information are relevant or irrelevant to their specific areas and thus improve the comprehensiveness of the information provided in report as a whole. If the report is not comprehensive enough, staff may revert to using traditional paper handoffs as a way to fulfill their handoff needs (Staggers et al. 2012). While it may be difficult to properly balance some of the key characteristics identified, such as customization and standardization, the benefits of a well-implemented and adopted e-handoff report tool can outweigh the costs overall.
This systematic review may have been restricted by the limited search methods used which consisted of two main search terms of “EHR” and “handoff.” These terms may not have incorporated all related terms for a study on this topic. The authors attempted to supplement this by handsearching relevant articles that met the inclusion/exclusion criteria. However, the possibility of omitting important research remains. Randomized controlled trials specific to the subject of this review could not be located, perhaps due to the nature of the topic being studied. Quality measures are most often used when reviewing characteristics of successful interventions. It is also possible that many quality improvement projects are missing from research databases as they often are not published in peer-reviewed journals and only used at institutions internally (Davis et al., 2015).
Communication errors in the health care setting are one of the major contributors to adverse events, causing significant costs to health care organizations and potential harm to patients every year. The health care industry requires a proactive approach to safety with a crucial focus on anticipating and preventing complications to avoid catastrophic events. EHR-supported handoff tools are not yet widely available across different EHRs, and those that are available have not been well adopted for a variety of reasons. By involving end users in the creation of e-handoff tools and ensuring that they provide a comprehensive, standardized, aesthetic and mobile report with enough flexibility for some end-user customization, the tools can be more widely adopted and used.
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Theodore M. Aronson MSN, RN-BC
Mr. Theodore M. Aronson, MSN, RN-BC is a clinical informatics educator at Stanford Health Care in Palo Alto, California. Previously, he practiced as a neurosurgery nurse at Medstar Georgetown University Hospital and served as the hospital-wide nursing EHR instructor and as the chair of the nursing evidence-based practice and research council. He has a BSN from James Madison University in Harrisonburg, Va., and an MSN from the University of Maryland, Baltimore.
Sarah E. Oertle MSN, RN
Ms. Sarah E. Oertle, MSN, RN-BC is an informatics nurse specialist at VCU Health in Richmond, Virginia. Previously, she practiced as a registered nurse in multiple settings including inpatient, home health, and outpatient surgery. She has a BSN from Regis University in Denver, Colo., and an MSN from the University of Maryland, Baltimore.
Ronald J. Piscotty Jr., PhD, RN-BC, FAMIA
Dr. Ronald J. Piscotty, Jr., PhD, RN-BC, FAMIA is an assistant professor at the University of Maryland School of Nursing in the Department of Organization Systems and Adult Health and teaches primarily in the nursing informatics specialty. Dr. Piscotty has a BSN from Wayne State University in Detroit, Michigan, and a MS and PhD in nursing systems from the University of Michigan, Ann Arbor. Dr. Piscotty is board certified in informatics nursing from the American Nurse Credentialing Center and a fellow of the American Medical Informatics Association.