CC BY-NC-ND 4.0 · Appl Clin Inform 2021; 12(05): 1120-1134
DOI: 10.1055/s-0041-1740256
Research Article

A Mobile, Electronic Health Record-Connected Application for Managing Team Workflows in Inpatient Care

Jacqueline M. Soegaard Ballester
1   Division of General Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
Geoffrey D. Bass
2   Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
Richard Urbani
3   Department of Information Services, Penn Medicine, Philadelphia, Pennsylvania, United States
Glenn Fala
3   Department of Information Services, Penn Medicine, Philadelphia, Pennsylvania, United States
Rutvij Patel
3   Department of Information Services, Penn Medicine, Philadelphia, Pennsylvania, United States
Damien Leri
4   Center for Healthcare Innovation, Penn Medicine, Philadelphia, Pennsylvania, United States
Jackson M. Steinkamp
5   Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
Joshua L. Denson
6   Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States
Roy Rosin
4   Center for Healthcare Innovation, Penn Medicine, Philadelphia, Pennsylvania, United States
7   Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States
Srinath Adusumalli
8   Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
Clarence William Hanson
9   Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
10   Office of the Chief Medical Information Officer, Penn Medicine, Philadelphia, Pennsylvania, United States
Ross Koppel
7   Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States
11   Institute of Biomedical Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
12   Department of Sociology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, United States
13   Department of Biomedical informatics, University of Buffalo (SUNY), Buffalo, New York, United States
Subha Airan-Javia
14   Section of Hospital Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
15   Founder/CEO, CareAlign, Philadelphia, Pennsylvania, United States
› Author Affiliations


Background Clinical workflows require the ability to synthesize and act on existing and emerging patient information. While offering multiple benefits, in many circumstances electronic health records (EHRs) do not adequately support these needs.

Objectives We sought to design, build, and implement an EHR-connected rounding and handoff tool with real-time data that supports care plan organization and team-based care. This article first describes our process, from ideation and development through implementation; and second, the research findings of objective use, efficacy, and efficiency, along with qualitative assessments of user experience.

Methods Guided by user-centered design and Agile development methodologies, our interdisciplinary team designed and built Carelign as a responsive web application, accessible from any mobile or desktop device, that gathers and integrates data from a health care institution's information systems. Implementation and iterative improvements spanned January to July 2016. We assessed acceptance via usage metrics, user observations, time–motion studies, and user surveys.

Results By July 2016, Carelign was implemented on 152 of 169 total inpatient services across three hospitals staffing 1,616 hospital beds. Acceptance was near-immediate: in July 2016, 3,275 average unique weekly users generated 26,981 average weekly access sessions; these metrics remained steady over the following 4 years. In 2016 and 2018 surveys, users positively rated Carelign's workflow integration, support of clinical activities, and overall impact on work life.

Conclusion User-focused design, multidisciplinary development teams, and rapid iteration enabled creation, adoption, and sustained use of a patient-centered digital workflow tool that supports diverse users' and teams' evolving care plan organization needs.

Author Contributions

Application conception, design, or development: Soegaard, Urbani, Fala, Patel, Leri, Rosin, Hanson, and Airan-Javia. Application implementation: Soegaard, Bass, Urbani, Patel, Leri, and Airan-Javia. Acquisition of data: Urbani, Patel, and Airan-Javia. Analysis or interpretation of data: Soegaard, Urbani, Koppel, and Airan-Javia. Drafting of manuscript: Soegaard, Steinkamp, Denson, Koppel, and Airan-Javia. Critical revision of the manuscript for important intellectual content: Soegaard, Bass, Urbani, Fala, Patel, Leri, Steinkamp, Denson, Rosin, Adusumalli, Hanson, Koppel, and Airan-Javia. Executive, administrative, technical, or material support: Urbani, Fala, Patel, Rosin, and Hanson. Study supervision: Airan-Javia.

Protection of Human and Animal Subjects

No human or animal subjects were directly involved in this project. This project was reviewed and categorized as quality improvement by the University of Pennsylvania Institutional Review Board and was therefore exempt from approval.

Supplementary Material

Publication History

Received: 27 April 2021

Accepted: 11 October 2021

Article published online:
22 December 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

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  • References

  • 1 Henry J, Pylypchuk Y, Searcy T, Patel V. ONC Data Brief 35: Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals (2008-2015); 2016. Available at:
  • 2 Jamoom EW, Patel V, Furukawa MF, King J. EHR adopters vs. non-adopters: Impacts of, barriers to, and federal initiatives for EHR adoption. Healthc (Amst) 2014; 2 (01) 33-39
  • 3 Karsh BT, Weinger MB, Abbott PA, Wears RL. Health information technology: fallacies and sober realities. J Am Med Inform Assoc 2010; 17 (06) 617-623
  • 4 Koppel R, Kuziemsky C. Usability across health information technology systems: searching for commonalities and consistency. Stud Health Technol Inform 2019; 264: 649-653
  • 5 Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016; 353: i2139
  • 6 Abraham J, Kannampallil T, Patel VL. A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. J Am Med Inform Assoc 2014; 21 (01) 154-162
  • 7 Denson JL, Jensen A, Saag HS. et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA 2016; 316 (21) 2204-2213
  • 8 Melnick ER, Dyrbye LN, Sinsky CA. et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clin Proc 2020; 95 (03) 476-487
  • 9 Shanafelt TD, Dyrbye LN, Sinsky C. et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc 2016; 91 (07) 836-848
  • 10 Babbott S, Manwell LB, Brown R. et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc 2014; 21 (e1, E2): e100-e106
  • 11 Spinelli WM, Fernstrom KM, Britt H, Pratt R. “Seeing the patient is the joy:” a focus group analysis of burnout in outpatient providers. Fam Med 2016; 48 (04) 273-278
  • 12 Yan Q, Jiang Z, Harbin Z, Tolbert PH, Davies MG. Exploring the relationship between electronic health records and provider burnout: a systematic review. J Am Med Inform Assoc 2021; 28 (05) 1009-1021
  • 13 Sinsky C, Colligan L, Li L. et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016; 165 (11) 753-760
  • 14 Overhage JM, McCallie Jr D. Physician time spent using the electronic health record during outpatient encounters: a descriptive study. Ann Intern Med 2020; 172 (03) 169-174
  • 15 Beasley JW, Wetterneck TB, Temte J. et al. Information chaos in primary care: implications for physician performance and patient safety. J Am Board Fam Med 2011; 24 (06) 745-751
  • 16 Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspect Health Inf Manag 2013; 10 (Fall): 1c
  • 17 Carayon P, Du S, Brown R, Cartmill R, Johnson M, Wetterneck TB. EHR-related medication errors in two ICUs. J Healthc Risk Manag 2017; 36 (03) 6-15
  • 18 Leventhal R. Malpractice claims report: EHR documentation errors still far too common. Healthcare Innovation. Published November 4, 2020. Accessed March 20, 2021 at:
  • 19 Friedberg MW, Chen PG, Van Busum KR. et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q 2014; 3 (04) 1
  • 20 Starren JB, Tierney WM, Williams MS. et al. A retrospective look at the predictions and recommendations from the 2009 AMIA policy meeting: did we see EHR-related clinician burnout coming?. J Am Med Inform Assoc 2021; 28 (05) 948-954
  • 21 Tajirian T, Stergiopoulos V, Strudwick G. et al. The influence of electronic health record use on physician burnout: cross-sectional survey. J Med Internet Res 2020; 22 (07) e19274
  • 22 Smith SW, Koppel R. Healthcare information technology's relativity problems: a typology of how patients' physical reality, clinicians' mental models, and healthcare information technology differ. J Am Med Inform Assoc 2014; 21 (01) 117-131
  • 23 Abbott PA, Weinger MB. Health information technology: fallacies and sober realities - redux a homage to Bentzi Karsh and Robert Wears. Appl Ergon 2020; 82: 102973
  • 24 Miljanic M, Zaric N. Review of collaborative software applications and integration with standard collaboration tools. In: 2020 24th International Conference on Information Technology, IT 2020. Institute of Electrical and Electronics Engineers Inc.; 2020
  • 25 Vidyarthi AR, Coffey M. Paperless handover: are we ready?. BMJ Qual Saf 2016; 25 (05) 299-301
  • 26 Ham III PB, Anderton T, Gallaher R. et al. Development of electronic medical record-based “Rounds Report” results in improved resident efficiency, more time for direct patient care and education, and less resident duty hour violations. Am Surg 2016; 82 (09) 853-859
  • 27 Aylward MJ, Rogers T, Duane PG. Inaccuracy in patient handoffs: discrepancies between resident-generated reports and the medical record. Minn Med 2011; 94 (12) 38-41
  • 28 Emanuele J, Koetter LE. Workflow opportunities and challenges in healthcare. BPM & Workflow Handbook 1: 157. 2007;(July). Accessed November 15, 2021 at:
  • 29 Li P, Ali S, Tang C, Ghali WA, Stelfox HT. Review of computerized physician handoff tools for improving the quality of patient care. J Hosp Med 2013; 8 (08) 456-463
  • 30 Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 1998; 24 (02) 77-87
  • 31 Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg 2005; 200 (04) 538-545
  • 32 Antoine Geissbuhler RAM. WizOrder, a user-friendly interface for order entry and clinical decision support tools. Proc Annu Symp Comput Appl Med Care 1995; 1002
  • 33 Miller RA, Waitman LR, Chen S, Rosenbloom ST. The anatomy of decision support during inpatient care provider order entry (CPOE): empirical observations from a decade of CPOE experience at Vanderbilt. J Biomed Inform 2005; 38 (06) 469-485
  • 34 Duke JD, Morea J, Mamlin B. et al. Regenstrief Institute's Medical Gopher: a next-generation homegrown electronic medical record system. Int J Med Inform 2014; 83 (03) 170-179
  • 35 Yount RJ, Vries JK, Councill CD. The medical archival system: an information retrieval system based on distributed parallel processing. Inf Process Manage 1991; 27 (04) 379-389
  • 36 Giuse DA. Supporting communication in an integrated patient record system. AMIA Annu Symp Proc 2003; 1065
  • 37 Giuse NB, Williams AM, Giuse DA. Integrating best evidence into patient care: a process facilitated by a seamless integration with informatics tools. J Med Libr Assoc 2010; 98 (03) 220-222
  • 38 Dullabh P, Hovey L, Heaney-Huls K, Rajendran N, Wright A, Sittig DF. Application programming interfaces in health care: findings from a current-state sociotechnical assessment. Appl Clin Inform 2020; 11 (01) 59-69
  • 39 Abbott PA. The effectiveness and clinical usability of a handheld information appliance. Nurs Res Pract 2012; 2012: 307258
  • 40 Rosenbluth G, Jacolbia R, Milev D, Auerbach AD. Half-life of a printed handoff document. BMJ Qual Saf 2016; 25 (05) 324-328
  • 41 Derienzo C, Lenfestey R, Horvath M, Goldberg R, Ferranti J. Neonatal intensive care unit handoffs: a pilot study on core elements and epidemiology of errors. J Perinatol 2014; 34 (02) 149-152
  • 42 Boustani MA, van der Marck MA, Adams N. et al. Developing the agile implementation playbook for integrating evidence-based health care services into clinical practice. Acad Med 2019; 94 (04) 556
  • 43 Papoutsi C, Wherton J, Shaw S, Morrison C, Greenhalgh T. Putting the social back into sociotechnical: case studies of co-design in digital health. J Am Med Inform Assoc 2021; 28 (02) 284-293
  • 44 Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf 2006; 32 (11) 646-655
  • 45 Starmer AJ, O'Toole JK, Rosenbluth G. et al; I-PASS Study Education Executive Committee. Development, implementation, and dissemination of the I-PASS handoff curriculum: a multisite educational intervention to improve patient handoffs. Acad Med 2014; 89 (06) 876-884
  • 46 Melnick ER, Sinsky CA, Krumholz HM. Implementing measurement science for electronic health record use. JAMA 2021; 325 (21) 2149-2150
  • 47 Adusumalli S, Siddique S, Airan-Javia S. Carelign: closing the loop on inpatient consultant communication. In: Academy Health Conference Proceedigs. Academy Health; 2017. Accessed November 15, 2021 at:
  • 48 Shafer BM, Gorry T, Tapino P, Airan-Javia S. Carelign: a novel handoff system for medical and surgical consultants. Nepal J Ophthalmol 2020; 12 (01) e63-e66
  • 49 Miller DM, Schapira MM, Visotcky AM. et al. Changes in written sign-out composition across hospitalization. J Hosp Med 2015; 10 (08) 534-536
  • 50 Airan-Javia SL, Kogan JR, Smith M. et al. Effects of education on interns' verbal and electronic handoff documentation skills. J Grad Med Educ 2012; 4 (02) 209-214
  • 51 Hartung DM, Hunt J, Siemienczuk J, Miller H, Touchette DR. Clinical implications of an accurate problem list on heart failure treatment. J Gen Intern Med 2005; 20 (02) 143-147
  • 52 Wright A, McCoy AB, Hickman T-TT. et al. Problem list completeness in electronic health records: a multi-site study and assessment of success factors. Int J Med Inform 2015; 84 (10) 784-790
  • 53 Rosenbloom ST, Denny JC, Xu H, Lorenzi N, Stead WW, Johnson KB. Data from clinical notes: a perspective on the tension between structure and flexible documentation. J Am Med Inform Assoc 2011; 18 (02) 181-186
  • 54 Wright A, Maloney FL, Feblowitz JC. Clinician attitudes toward and use of electronic problem lists: a thematic analysis. BMC Med Inform Decis Mak 2011; 11 (01) 36
  • 55 Starmer AJ, Spector ND, Srivastava R. et al; I-PASS Study Group. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014; 371 (19) 1803-1812
  • 56 Weed LL. Medical records that guide and teach. N Engl J Med 1968; 278 (12) 652-657