Electronic Health Records and Interprofessional Collaboration: A Constructivist Grounded Theory of Information Exchange in Inpatient Care

Technical Summary: Electronic Health Records and Interprofessional Collaboration

Problem Statement
While Electronic Health Records (EHRs) are positioned as the central infrastructure for information exchange in inpatient care, persistent challenges limit their ability to support effective interprofessional collaboration (IPC). Existing research has predominantly focused on technical system features or individual user experiences, often overlooking the specific clinical activities through which care is organized. Consequently, analyses risk obscuring how EHRs shape coordination in practice, potentially reinforcing workflow breakdowns rather than addressing the dynamic demands of inpatient work. In teaching hospitals characterized by frequent staff transitions and shifting patient acuity, the misalignment between EHR design and the complex, interdependent workflows of diverse professional groups remains a critical barrier to timely and accurate information exchange.

Methodology
This study employed an ethnographically informed constructivist grounded theory (CGT) approach, guided by a sociotechnical systems (STS) perspective. The research was conducted over a fifteen-month period (October 2024 – December 2025) on an inpatient medicine unit at a large academic health sciences centre in Southwestern Ontario, Canada.

• Data Collection: The primary data source consisted of over 220 hours of direct observation across four interprofessional teams. Observations covered routine and high-stakes activities, including nursing handovers, interprofessional rounds, bedside care, and EHR-mediated tasks (documentation, order entry, result review). These observations were supplemented by brief field interviews conducted during or immediately after observations to elicit tacit knowledge, and follow-up in-depth interviews with 51 participants (including physicians, nurses, pharmacists, therapists, and IT staff).
• Analysis: Data collection and analysis occurred iteratively. Field notes and interview transcripts were coded to identify recurring patterns. Analytic categories were developed inductively through memo writing, diagramming, and team discussions, with a specific focus on how digital tools, clinical tasks, and organizational structures interact to shape IPC. The analysis was grounded in the STS framework, examining the interdependencies between system structures and clinical work.

Key Contributions
The study advances the literature by shifting the analytical focus from static system features to the dynamic clinical activities through which IPC is enacted. It introduces a nuanced distinction between intraprofessional and interprofessional EHR support, demonstrating that EHRs often function effectively within professional silos but fail to support cross-role coordination. Furthermore, the paper operationalizes "information quality" not merely as data accuracy, but as a triad of completeness, interpretability, and coordinative timeliness that is essential for shared situational awareness. Finally, it reframes informal coordination practices (e.g., verbal handovers, physical notes) not as system failures to be eliminated, but as rational adaptations to systemic misalignments that form a parallel coordination infrastructure.

Results
The analysis identified that the EHR system primarily fulfilled three functions: acting as a repository for past documentation, supporting task assignment and new information sharing, and collating patient data. However, these functions aligned more strongly with intraprofessional workflows than with the activities required for IPC.

The misalignment between EHR design and clinical needs became visible through four specific clinical activities:

1. Triage: The EHR lacked mechanisms to convey patient acuity or task urgency across professional boundaries. While nursing dashboards used color-coding for task status, the system did not differentiate between high-risk clinical actions and low-risk documentation, nor did it visualize cross-role dependencies (e.g., waiting for a physician order before a pharmacist can act).
2. Information Sharing: Structured, task-oriented data (e.g., lab values, medication orders) circulated effectively. However, interpretive and contextual knowledge (e.g., clinical reasoning, functional decline) was often lost because it was recorded in narrative notes that were not routinely reviewed across roles. Physician communication orders, while automatically routed, often created information overload, obscuring current relevance.
3. Information Analysis and Synthesis: Clinicians struggled to synthesize a coherent patient narrative due to fragmented documentation. Relevant details were scattered across profession-specific sections (e.g., nursing vs. physician notes), and problem lists were inconsistently updated. This forced clinicians to reconstruct patient understanding through additional assessments or family contact rather than relying on the EHR.
4. Orientation to Patient Status: The EHR failed to provide a real-time, shared view of the patient's current condition. Interventions (e.g., catheter removal) often remained listed as "active" in certain views despite being completed, and physicians lacked visibility into the completion status of nursing tasks. Automated tools (e.g., NEWS scores) were underutilized or misunderstood.

Significance and Claims
The paper claims that EHRs in inpatient settings currently function more as profession-specific repositories than as shared coordination infrastructures. The study argues that the effectiveness of EHRs in supporting IPC is contingent rather than uniform; it depends on the alignment between system structures and the specific information demands of clinical activities.

The authors emphasize that the core challenge is not the availability of information, but its representation, interpretation, and visibility across professional roles. When the EHR fails to meet requirements for completeness, interpretability, and coordinative timeliness, clinicians rely on informal coordination practices to maintain shared awareness. The paper concludes that rather than attempting to eliminate these informal practices, which are intrinsic to complex clinical work, system optimization efforts must focus on aligning formal EHR representations with the actual workflows of interprofessional collaboration. This requires moving beyond technical optimization to address the sociotechnical misalignments that fragment information exchange across professional boundaries.