Table 1:

Common Themes from Observations, Interviews and Focus Groups

Domains	Challenges	Suggested Improvements
Communication	One-way communication tools. Using pagers, the EHR, or other one-way modes is inefficient, causes delays, and doesn’t allow participants to convey context or have a discussion Constant pages. The large number of pages interrupts thinking required for diagnosis and patient care Non-prioritized pages. Frequent pages related to routine patient care can lead to ‘alert fatigue’ Inadequate face-to-face communication. Limited opportunity to discuss and think through diagnosis, including with nurses and specialty consultants	Replace current pagers. Instead use only two-way communication devices such as phones or pagers that have text-back features ‘Batch’ pages and emails. For messages related to routine care, messages should be grouped together and sent at one time Prioritization of critical pages. Implement a new system that allows physicians to triage most critical pages and read others at a later time More discussion and conversation is needed. Clinicians need to make the time to talk face-to-face with each other about diagnosis
EHR Data Sharing	Fragmentation of Information. Gathering and receiving diagnostic information was fragmented Data overload. Physicians face information and data overload in EHR Not designed for diagnosis. EHR does not support thinking about diagnosis Limited access. EHR access may be limited or not available during morning rounds when diagnosis is discussed Lack of knowledge and efficacy. Physicians may not be aware of how to use the EHR to facilitate diagnosis.	Restructure EHR. Restructure to support diagnosis and decision making Integrate data. Improve the integration of patient data (labs, imaging, test results, notes) to make it easier to see the full clinical picture and display in more clinically relevant ways Reduce data overload. Consider eliminating auto-populating options and creating alerts or notifications of new test results or updates Streamline. Improve process for ordering, collecting and expediting labs/test results Use laptops, computers on wheels, tablets, phones, or other technologies to access to EHR during morning rounds Physician trainings. Are needed on how to better use EHR to improve diagnosis