“We should see workarounds as valuable feedback, rather than turning a blind eye”

We all use workarounds in our job, temporary solutions, bypasses, that deviate from the way things should be done. Sometimes this works out well, sometimes there are drawbacks. Iris Beerepoot is a lecturer and researcher at Utrecht University and wrote her PhD dissertation on workarounds in Health Information Systems.  “Once you start noticing, you see them everywhere.”

What is a typical workaround that is beneficial? Can you give an example?

Good workarounds in healthcare are often the moments when healthcare providers take a proactive approach to the patient and come up with something new to transfer information. An example of this are secretaries at a clinic, who have an extensive system for communicating with each other about the patients who are going to come to the consultation hours. To prevent patients from coming in vain, they check whether research results are in already. In the consultation hour overview they indicate with an asterisk that the results are in. The healthcare information system does not offer them the opportunity to systematically go through such an overview, so they have devised a way for them themselves. 

We've seen a similar kind of proactivity among nurses chasing doctors in various ways to ensure a patient can be discharged as soon as possible.

We saw similar workarounds in rehabilitation care. Rehabilitators often have busy programmes with physiotherapy, speech therapy, occupational therapy. When nurses had some time during the night shift, they made paper schedules for them, with clocks, pictograms, pictures of practitioners, etc. This information could also be found in the information system, but the printed version was illegible or incomprehensible for lots of patients.”

On the night shift, nurses made paper schedules with pictograms and clocks for the patients.

What kind of bad workarounds did you spot, during your research?

Bad workarounds often have to do with authorizations that are violated. An example of this is a doctor in training who is allowed to do more and more, but whose user account does not allow this. He or she therefore chooses to log in under a different account. We have also seen the sharing of user accounts among nurses, to quickly go through the four-eye check when administering medication. The consequence of this is that actions are difficult to trace back to persons, and sometimes there is also a direct risk for the patient.
What we also see a lot is that the standard fields in, for example, questionnaires for healthcare providers are not sufficient. They often want to provide additional information and use free text fields for this. The disadvantage of this is that this unstructured information cannot be used in calculations and analyses, and that this information is not always accessible to colleagues who have to work with it later on.

What did people tell you about the reasons they used workarounds?

The most common reason for using a workaround is to be able to provide good patient care. Whether healthcare providers feel that a calculation of fluid balance is incorrect and they therefore have to calculate it manually, or whether they want to communicate extra information about a patient to colleagues...  They usually do this out of a prominent sense of responsibility and the desire to treat the patient well, to assist. Perhaps this is precisely why they regularly run out of time and sometimes opt for the shorter route, which paradoxically does not always benefit the patient.

Care providers want to spend extra time with the patient, so they are short on time and start to use workarounds that do not necessarily benefit the patient.

How did you come up with this topic for your PhD?

This was a happy coincidence. I wanted to write my master's thesis within healthcare and ICT, and ended up at a consultancy company that specialized in supporting healthcare institutions in the implementation of healthcare information systems.

My thesis supervisor came up with the idea to look at workarounds. The results of that research at a hospital left me wanting more and we have therefore continued in the form of a doctoral research. I was able to conduct a study into workarounds at a total of seven healthcare institutions.

I find healthcare fascinating: it's knowledge-intensive, dynamic and has so many different stakeholders.

Why healthcare? 

I find healthcare fascinating because there are so many different stakeholders involved in processes. Care managers but also information managers view the use of workarounds very differently than the nurse and secretary on the work floor.

In addition, processes in healthcare are very knowledge-intensive and dynamic, with each situation standing on its own and requiring a different response. Care processes are much more than just the actions that are eventually registered in the information system, they are preceded by a lot of thinking and it is up to me to try to map a part of it, where I do not have the illusion that I ever have a complete picture. By the time I somewhat understand a process, the process has already changed. It's comforting to know that I could devote the rest of my life to this!(laughs)

What can we learn from your research for other fields of work?

Although I have conducted my research in healthcare, I am convinced that the results, methods and techniques are also relevant beyond that. In other domains too, everyone can recognize that information systems sometimes form an obstacle rather than a welcome support for activities. A recent example of this is that Dutch Minister Hugo de Jonge confessed he uses his private email for work matters because of the hassle with passwords. When users are forced to create a new complex password once in a while, they will look for alternatives. In this case, the alternative, the use of private mail, has a clear negative effect on the security and documentation of information.

I am convinced that we can avoid these kinds of workarounds if we are open to using them and think about good solutions together. We need to see workarounds as valuable feedback on the use of information systems in practice, rather than turning a blind eye.

The system you work with should be a support, not an obstacle.

Were there any results that surprised you? In a positive or negative sense?

I'm not surprised that workarounds are used, but I was surprised by the sheer amount of them! Once you start noticing, you see them everywhere. I now also realise how complex it is to set up a system that pleases everyone. For example, I've studied different doctors of the same specialism, but even among themselves you see big differences in how they work.

You will continue to work at Utrecht University, what's next?

I have been a teacher-researcher since January. Together with Inge van de Weerd and Wouter van der Waal, we are expanding research on workarounds in the Workaround Mining Lab. In addition, I am working on all kinds of fun new projects, all of which have to do with providing insight into how people work. On the one hand, we use process mining, a collection of data analysis techniques with which we can map processes based on data from information systems. On the other hand, we try to enrich that data by using other methods and techniques, such as observations, surveys and location data. I would like to get in touch with other researchers who are interested in this!