One of the least glamorous things I learned from clinic work is how much healthcare depends on unofficial systems. Someone keeps a second list because the official one is hard to scan. Someone writes a reminder on paper because the EMR alert is too easy to miss. Someone calls instead of using the formal channel because the formal channel is too slow.

That can look like bad process discipline. Sometimes it is. But when the same workaround keeps appearing, I think it is also data.

The research gives us a better frame than “resistance.”

Zheng, Ratwani and Adler-Milstein describe clinical workflow as the actual sequence through which care gets done, and show why studying EHR-supported workarounds can reveal opportunities for system improvement. A 2022 JMIR scoping review similarly treats workarounds as a sociotechnical phenomenon rather than a simple user-compliance problem.

The workaround may need to disappear. The need it is serving still needs an answer.

I would not romanticize it.

Some workarounds bypass safety controls, fragment the record or make information visible to only one person. The right question is not whether to tolerate every shortcut. It is what mismatch in the designed system made the shortcut useful in the first place.

Four questions before redesigning anything.

  • What is the workaround saving the person from — time, clicks, ambiguity, missing information or waiting?
  • Does it protect the patient from a gap, or create a new safety risk?
  • Who benefits locally, and who absorbs the extra work elsewhere?
  • If it disappeared tomorrow, what would break first?

A process map built from policy documents shows the system people intended to create. Workarounds show the system people actually have.

REFERENCES / FURTHER READING

  1. Zheng, Ratwani & Adler-Milstein. Studying Workflow and Workarounds in Electronic Health Record-Supported Work. Ann Intern Med. 2020. Annals of Internal Medicine — EHR Workflow and Workarounds ↗
  2. Blijleven, Hoxha & Jaspers. Workarounds in Electronic Health Record Systems. JMIR. 2022. JMIR — Workarounds in Electronic Health Record Systems ↗
  3. NISTIR 7988. Integrating Electronic Health Records into Clinical Workflow. NIST — Integrating EHRs into Clinical Workflow ↗

These are personal research notes and commentary. I link the underlying sources so the evidence can be checked directly.