Understanding how a tap on/tap off system supports clinical work in an emergency department: a qualitative study.

Understanding how a tap on/tap off system supports clinical work in an emergency department: a qualitative study - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice BMC Med Inform Decis Mak . 2026 Mar 7;26:123. doi: 10.1186/s12911-026-03424-1 Search in PMC Search in PubMed View in NLM Catalog Add to search Understanding how a tap on/tap off system supports clinical work in an emergency department: a qualitative study Melissa Baysari Melissa Baysari 1 Digital Health Human Factors Group, Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia Find articles by Melissa Baysari 1, ✉ , Kristian Stanceski Kristian Stanceski 1 Digital Health Human Factors Group, Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia 2 Palliative Care Services, Royal Prince Alfred Hospital, Sydney, Australia Find articles by Kristian Stanceski 1, 2 , Adeola Bamgboje-Ayodele Adeola Bamgboje-Ayodele 1 Digital Health Human Factors Group, Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia Find articles by Adeola Bamgboje-Ayodele 1 , Johannes Olivier P Reijnvaan Johannes Olivier P Reijnvaan 1 Digital Health Human Factors Group, Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia 3 Medical Informatics, University of Amsterdam, Amsterdam, The Netherlands Find articles by Johannes Olivier P Reijnvaan 1, 3 , Bzuayehu Abera Heres Bzuayehu Abera Heres 1 Digital Health Human Factors Group, Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia 4 Sydney Medical School, University of Sydney, Sydney, Australia Find articles by Bzuayehu Abera Heres 1, 4 , Valentina Lichtner Valentina Lichtner 5 School of Health Sciences, University of Manchester, Manchester, UK Find articles by Valentina Lichtner 5 , Simon Latham Simon Latham 6 Health Informatics, Royal Prince Alfred Hospital, Sydney, Australia Find articles by Simon Latham 6 , Olivia King Olivia King 7 Health Informatics Unit, Digital Health and Innovation, Sydney Local Health District, Sydney, Australia Find articles by Olivia King 7 , Carla Murley Carla Murley 6 Health Informatics, Royal Prince Alfred Hospital, Sydney, Australia Find articles by Carla Murley 6 , Chen Jason Qian Chen Jason Qian 6 Health Informatics, Royal Prince Alfred Hospital, Sydney, Australia Find articles by Chen Jason Qian 6 , Aaron Jones Aaron Jones 7 Health Informatics Unit, Digital Health and Innovation, Sydney Local Health District, Sydney, Australia Find articles by Aaron Jones 7 Author information Article notes Copyright and License information 1 Digital Health Human Factors Group, Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia 2 Palliative Care Services, Royal Prince Alfred Hospital, Sydney, Australia 3 Medical Informatics, University of Amsterdam, Amsterdam, The Netherlands 4 Sydney Medical School, University of Sydney, Sydney, Australia 5 School of Health Sciences, University of Manchester, Manchester, UK 6 Health Informatics, Royal Prince Alfred Hospital, Sydney, Australia 7 Health Informatics Unit, Digital Health and Innovation, Sydney Local Health District, Sydney, Australia ✉ Corresponding author. Received 2024 Oct 13; Accepted 2026 Mar 2; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13081518  PMID: 41794736 Abstract Background Single sign-on (SSO), tap-on-tap-off (TOTO) and virtual desktops (VD) are increasingly being used in hospitals to reduce the burden and risks of password management, but we know little about how these systems are used in practice. We aimed to understand whether, and if so, how and why a TOTO and VD solution supported clinical work in an emergency department (ED). Methods Qualitative descriptive design comprising interviews ( n = 17) and work observations (~ 7 h) with doctors and nurses in an Australian ED. Data collection and analysis were informed by the unified theory of acceptance and use of technology (UTAUT). Results Some participants perceived the TOTO-VD system as useful, however, most questioned the value of the system for ED work. Time to login was relatively long for the needs of the ED, which contributed to the system not being used as intended. Workarounds led to users being automatically logged out mid-task, which further contributed to clinicians’ negative experience with the system. There appeared to be limited use for, and potentially new risks introduced with a VD solution, where ED clinicians perceived there to be redundant control of access to computers. Conclusions The ED work context presented barriers to TOTO-VD adoption. The system did not support clinical work in an ED and so was worked around by clinicians. We recommend examining and understanding clinician work, including when and how computers are used and what systems are accessed, prior to implementation of any technological solution. Clinical trial number Not applicable. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-026-03424-1. Keywords: Tap on- tap off, Virtual desktop, Password management, Privacy Background Healthcare work in hospitals is highly mobile, dynamic and frequently interrupted. Clinicians are required to log in and out of multiple computer applications several times a day, taking valuable time, leading to frustration, impacting productivity and potentially contributing to clinician burnout [ 1 ]. As users view the logging-in and out process as a burden, they may revert to taking workarounds, such as sharing passwords and not logging out of systems [ 2 , 3 ], with implications for both security and accountability (i.e. visibility of who did what in a patient’s record). Single sign-on (SSO), tap-on-tap-off (TOTO) and virtual desktops (VDs) may be implemented to reduce the burden of password management [ 4 ]. With SSO systems, one log in and password grants a user access to all applications. When combined with TOTO or a proximity card, one ‘tap’ of an identification card to a card-reader will automatically log a user in to all applications, removing the requirement to log into any application using a password. When VD infrastructure is also in place, when a user taps on, the computer opens to where they left off on the last computer used. For clinical staff, it is expected that use of SSO, TOTO and VD solutions would generate significant time savings, improve security, would allow greater flexibility in locations and devices used for work, and so improve overall satisfaction [ 5 , 6 ]. However, evaluations of these systems to date have produced mixed results. In a survey study of clinicians working in a US hospital, implementation of a TOTO SSO system was reported to improve efficiency (faster logins) and security (fewer shared passwords) [ 4 ]. Similarly, a survey study investigating the implementation of SSO technology with added VD across five emergency departments in the US, found a positive relationship between the technology, user satisfaction, and willingness to recommend the technology [ 7 ]. In contrast, in a 15-month field study that examined use of SSO solution in a US general hospital, the SSO negatively impacted clinicians’ workflow and did not support their collaborative needs [ 8 ]. Different users required access to different information and applications (e.g. electronic medical record (EMR), bed allocation system) simultaneously when working collaboratively at a single computer, which was not possible with SSO [ 8 ]. Most existing literature on SSO and TOTO systems has focused on time and financial savings [ 5 , 6 , 9 , 10 ], without adequately addressing user acceptance or satisfaction, especially in the context of virtual desktops. Like any technological intervention, realisation of expected benefits of SSO, TOTO and VD is dependent on the solutions addressing users’ needs, aligning with clinical workflows, and being accepted and adopted by the intended end-users. However, little is known about how these technologies support clinical work and clinicians’ perceptions of their use. Our study contributed to filling this evidence-gap by investigating clinicians’ experiences of a TOTO and VD solution. Methods Aim We aimed to understand whether, and if so, how and why a TOTO and VD solution supported clinical work in an emergency department (ED) in Australia. Design Our study used a qualitative descriptive design, comprising semi-structured interviews and work observations. Setting and systems implemented This research was undertaken in a single 60-bed ED in a hospital in Sydney, Australia. The ED received approximately 85,000 patient visits per year. A TOTO and VD solution were implemented simultaneously in the ED on 14 February, 2023. The TOTO system allowed clinicians to use their staff ID card to ‘tap’ on and off at a card reader mounted on each computer to log in and out of their cloud-based virtual desktop. As shown in Fig. 1 , the TOTO-VD system implemented in this ED, included a ‘follow-me’ function so that a clinician’s own desktop was available on each computer they used, as they moved between workstations in the ED. As part of the SSO functionality, the system automatically signed users into the EMR and Microsoft Office applications such as email and Teams, but did not eliminate the requirement for users to enter their username and password to sign-off clinical orders in the EMR. For the TOTO-VD system to function as intended by designers, an individual must tap on at the card reader when they arrive at a workstation, and they must tap off when they leave the workstation. Fig. 1. Open in a new tab TOTO-VD workflow, as envisioned by designers (VD=virtual desktop) The new system was not implemented on all workstations in the ED. Users without a TOTO registration could use their username and password to access clinical applications on non-TOTO devices. This hybrid implementation was required for cases where clinicians from other hospital areas visited the ED and needed to access patient information despite not being pre-registered as TOTO-VD users. Theoretical approach This study was guided by the unified theory of acceptance and use of technology (UTAUT) [ 11 ]. UTAUT is a well-known and widely used technology acceptance model, and includes four domains which influence acceptance and use of technology (Table 1 ). UTAUT was used to inform our interview questions and data analysis. In addition, we also asked participants’ views on sustaining use, i.e. whether the TOTO-VD system should be maintained in the ED and implemented more widely across the rest of the hospital. Table 1. The unified theory of acceptance and use of technology (UTAUT) [ 11 ] Domain Description Performance expectancy The degree to which an individual believes that using the system will help him or her to attain gains in job performance Effort expectancy The degree of ease associated with the use of the system Social influence The degree to which an individual perceives that it is important others believe that he or she should use the new system Facilitating conditions The degree to which an individual believes that an organizational and technical infrastructure exists to support use of the system Open in a new tab Participants and recruitment All nurses and doctors working in the ED (total approx. 300) were eligible to take part. To recruit participants, email invitations were distributed to all medical and nursing staff (including up to four reminders), flyers were posted around the ED, and researchers attended department meetings to outline the proposed study and answer any questions. All participants provided written informed consent prior to taking part in an interview or observation session. Procedure Semi-structured interviews were held with nurses and doctors in an office, meeting room or quiet location in the ED. Interviewers (JOR, BAH and KS) were medical and medical informatics students, independent from the ED, who received a 1-hour training session by a Professor of Human Factors, highly experienced in qualitative research, on how to perform interviews, and participated in several supervised practice interviews prior to undertaking formal data collection. Interview questions explored staff views of the TOTO-VD system, including benefits experienced and any challenges encountered. In particular, questions were designed to capture all elements of the UTAUT model (see Appendix 1 ), but were semi-structured so were adjusted depending on participants’ responses and reported experiences. Interviews were audio-recorded and transcribed verbatim. To complement interviews, the student data collectors also observed nurses and doctors using TOTO-VD workstations during routine work in the ED. Participants were shadowed for a maximum of 2 h, to avoid observer and participant fatigue. Hand-written notes were taken during observations on how the TOTO-VD system was used, or not used, how it performed, and any obvious benefits or problems encountered by clinicians. Data analysis Guided by UTAUT, researchers thematically analysed observation and interview data using both an inductive and deductive approach, as explained below [ 12 ]. Following Braun and Clark’s thematic analysis approach [ 13 ], interview and observation data were reviewed and then quotes and fragments of data were extracted and assigned initial codes. These codes were then mapped to the four domains of the UTAUT. After an initial independent analysis of a sample of interviews ( n = 2, then n = 4), four researchers (JOR, BAH, MB and ABA) came together to discuss and reach a consensus on the codes that had emerged from the data within each UTAUT domain, and to develop a coding framework for analysis of the remaining data. Following this, the remainder of the interviews and observation notes were analysed by at least two investigators using the coding framework (KS, VL, MB and ABA). The team then came together to discuss the codes identified, and to group the codes into themes, according to the main findings that emerged from the data. The team comprised both senior and junior researchers in Human Factors, sociotechnical systems, and digital health, with experience and expertise in the evaluation of a range of health technologies in practice. A Human Factors lens, which views people as one component of a complex sociotechnical system, underpinned the project and data analysis approach. As data analysis occurred concurrently with data collection, interviews and observations continued until thematic saturation was reached, i.e. no new themes were identified in transcripts and observation notes [ 14 ]. Results Participants In total, 10 nurses and 7 doctors participated in a semi-structured interview. Interviews lasted on average 12.5 min (range 3–29.5 min). Demographic information appears in Appendix 2 . Twelve of these participants (8 nurses and 4 doctors) were also observed interacting with TOTO-VD workstations while in the ED for a total of approximately 7 h. All observations occurred on weekdays, between 9am and 5pm, and were conducted during routine shifts and during nursing and medical handovers. In the following sections, interview quotes are identified with a N or D to represent nurses and doctors respectively. We did not identify themes related to social influence, so we present our findings as they relate to the remaining three domains of UTAUT, performance expectancy, effort expectancy and facilitating conditions, and to our additional questions on sustained use. Figure 2 provides a summary of the main findings that emerged from interviews and observations. Fig. 2. Open in a new tab Key themes from observations and interviews. Green boxes represent positive themes and orange boxes represent negative themes (VD=virtual desktop, EMR=electronic medical record, ED=emergency department) Performance expectancy – perceptions on gains being achieved in job performance Participants held variable views about the benefits achieved following implementation of the TOTO-VD system, with some reporting they would like to continue to use the system and others expressing a preference to revert to the previous way of working. Some participants described benefits of the TOTO-VD system, such as time savings, and the system supporting busy, interrupted and mobile work. A small number of participants also highlighted the potential privacy and security benefits following TOTO-VD system introduction. So it’s quite good to be able to jump around easily without logging in every time manually. (N1) I’d say a large increase in efficiency…if we just talk about logging onto and off computers , if that’s 100% of the time , then I’d say it cuts down your time by about 40% of that. (D3) […] people can’t see […] patient notes […] we’re always meant to log off from systems. That people can’t use your profile for things […] from that perspective , I thought it was a good idea. (D4) In contrast, many participants questioned the value of the TOTO-VD system for ED clinicians, particularly the virtual desktop solution. Clinicians raised two main concerns: (1) limited value in accessing applications outside of the EMR, and (2) limited value with respect to privacy and confidentiality. Participants explained that apart from the EMR, access to other applications like email, was not needed in the ED. It interferes with speed of access to what we should be doing , which is looking at patients’ notes and seeing data about patients. The idea of me wanting to join Teams on one computer , writing a letter on another computer , is just nonsense. (D2) I don’t use Teams often when I’m on the floor , and emails will just be if I have something specific that I need to look at in my emails , I don’t open every day or anything like that. (N11) Work observations confirmed this finding. Doctors and nurses were observed to use the EMR and occasionally accessed the internet or intranet for information (e.g. injectable drug list), but were not observed to use other applications, like Teams or email, while in the ED. As a result, it was not clear to users what need the TOTO solution was addressing or what value-add the VD was providing. Adding to user frustration, clinicians explained how applications like Teams would automatically open when a user tapped on, even if the user had no intention of accessing them. Teams is the one that is the first one that comes up , and it is just infuriating. (D2) With respect to privacy, many participants did not view privacy and confidentiality to be a problem in the ED prior to TOTO-VD system implementation, and did not perceive improvements in patient confidentiality, privacy and security to be rationale for introducing the TOTO-VD system. So my question is , ‘what are the security issues?’ You’ve got a group of doctors and nurses working in an ED , what are the security issues? […] I don’t know that there are any (D2) Some participants reported that the VD solution had increased the risk of privacy and security breaches because tapping onto a computer potentially provided other people with access to confidential documents and emails, that were previously not accessible to staff on the ED workstations. Some doctors and nurses explained that they were required to be extra vigilant and tap off when leaving a workstation, even for short periods of time, because of this increased risk. However , I have to be vigilant with that because it actually has my virtual desktop , which has confidential documents that’s related to my non clinical work. So I have to be mindful of those. And again , people can use my FirstNet , my Teams , my Email , if I tap on and leave it on , leave it on for people to see. (N7) Despite participants reporting this, work observations revealed that clinicians frequently tapped on when arriving at a workstation, but did not often tap off. All clinicians observed did, at least on one occasion, step away from the computer without tapping off. Analysis of our observations of staff interacting with TOTO-VD while in the ED revealed a discordance between the way the system was designed or expected to be used (Fig. 1 ) and the way it was used in practice. Figure 3 shows the scenarios most frequently observed to occur. After first tapping on, clinicians did not tap off and were automatically logged out of their VD when they tapped on at another computer (self-initiated), or another user tapped on at their computer (colleague-initiated). Fig. 3. Open in a new tab Automatic log-out scenarios (VD=virtual desktop) Effort expectancy – perceptions on ease of use of the TOTO-VD system Most participants described the TOTO-VD system as easy to learn and to use. However, many clinicians described system glitches and crashes, card reader malfunctions, and variable system performance. Some reported the VD not working as intended. what I find is they don’t work the way that they should in that , when I say I’ve got EMR up , […] on one computer and then I go and I tap off , or I tap off and I tap on elsewhere. It won’t bring up where I was previously which is frustrating. I would say more often than not , that doesn’t happen. [N3] Almost all nurses and doctors described the log in process as slow, many describing the log in process with TOTO as slower than the previous manual process. But it’s actually really slow. Like it is slower than just logging on. (D7) […] we’re so pressured for time in here that anything that slows you down even for five minutes or three minutes more than it needs to be , feels like a very long time. (N8) This finding was also confirmed by observations. In over half of the attempts observed to access TOTO-VD on workstations, users encountered problems, such as significant delays, error messages, or frozen screens. Participants described many negative consequences of a slow system, for both patients and clinicians. One participant perceived that they had less time to dedicate to patient care, and that patient care was being delayed as a result of the TOTO-VD system. Some participants described workarounds (e.g. using paper while waiting for the system to be ready) and reported that less documentation was being completed in real-time as a result of system lags. Clinicians described feeling frustrated and stressed, and these reactions were also frequently observed to occur during our observations. There’ll be a list of patients that you need to go see , but you’re like , well , I can’t do anything because it’s still loading. (N5) A major consequence of the slow processing times was that clinicians would intentionally not tap off, to avoid the lengthy log-in times if they were required to tap back on. So certainly the time lag and the time factor is a bit of a problem , particularly when you’re making multiple transactions. To be honest , that’s probably one of the reasons why you become a little bit complacent with tapping off (N7) Participants also reported that staff had become more protective of their computers, to avoid being logged out and having to log back in. And it means that people are far more protective of their computers , […] because it logs them entirely off. And then it’s the problem of rebooting so when they come back on. It has to load the whole thing again. (D5) Facilitating conditions – perceptions on what supports use of the new system Among the conditions facilitating, or more generally influencing, TOTO-VD system use, we identified barriers more than facilitators. Key barriers to TOTO-VD system use, or to the system not being used as intended, included the presence of a hybrid system in the ED, limited availability of computers, and limited understanding of the virtual desktop solution among some clinicians. The most significant problem identified was that not all clinicians were registered to use the system. I just think it’s always going to be fiddly until everyone does it , or you have to have , you know , in resus get some computers that aren’t tap on. Because when you’re in resus , the trauma team is coming , neuro surg is coming , cardiology is coming , everybody is coming. And they don’t have access. (D5) Many participants described how clinicians (e.g. doctors and allied health staff) with no TOTO-VD authorisation were required to use TOTO-VD computers in the ED. Two scenarios were observed to occur in this case: (1) visiting staff would ask an ED staff member to tap on at a computer for them, or (2) visiting staff would find a TOTO-VD computer not in use where the user had not logged out. In both cases, the visiting staff member would log into their EMR while using someone else’s virtual desktop, as in Fig. 4 . The consequences of a user manually logging into their own EMR while still signed in to another user’s VD were observed to be significant. Accessing an EMR in a colleague’s VD gives the owner of the VD access to your EMR, and there is a high probability of being automatically logged out mid-task as a result of the owner of VD tapping on at another computer. Fig. 4. Open in a new tab Consequences of not tapping on at a workstation (VD=virtual desktop, EMR=electronic medical record) Insufficient computers was also highlighted to be problematic by both doctors and nurses. In here , the turnaround for a workstation is very quick , I could be gone for 10 seconds…and someone else will be using it. That is the demand of the workstations and the technology that we have in this workspace being a predominantly electronic system. (N7) Among the facilitating conditions was the ease of initial user registration onto the new system. Most participants described the initial implementation process as positive, particularly the launch and early registration process. It was pretty seamless. Like I was activated within 24 hours. (N3) However, some clinicians described challenges with the training and the registration and onboarding process for new users. Our observations suggested participants appeared to have a poor understanding of the VD solution and how it worked. One participant was seen to manually close all applications when roaming between computers; this defeats the purpose of the ‘follow-me’ function, and potentially indicates additional training is needed. I’m not a technical person , it might have been good to have a bit more understanding about the cloud side of things. like they [implementation team] were so excited about that particular function , and it probably hasn’t translated to the clinicians so well. (N1) Sustained use – perceptions on whether the TOTO-VD system should continue and be implemented more widely When asked about the future of the TOTO-VD system, most participants envisaged that having all staff registered with the system would eliminate some of the problems experienced in the ED, but some participants questioned whether widespread use was needed. Clinicians were not convinced that the TOTO-VD system would add value outside of the ED on the wards and support ward staff workflows. I just think because upstairs [in clinical wards]…a lot of time you’ve got two people logged in at once. And I think if you’re always tapping , tapping , you kind of dibs the whole computer to yourself , which is difficult when you’re on the ward , especially like a ward with like , 40 patients , you’ve got four computers , like the nurses are using them , you’re using them , and I think it’ll just get so frustrating. D5 If widespread use was planned, participants said that it was essential that this be accompanied by more computers and improvements to the TOTO-VD system performance. Discussion This study revealed that the TOTO-VD solution was not being used in the way it was intended to be used. Although it was expected that clinicians would tap on and off various computers in the ED and access a variety of applications, this was not observed to occur most of the time. Clinicians tapped on, but rarely tapped off. Clinicians also rarely accessed systems outside of the EMR while in the ED. User workarounds, coupled with a hybrid implementation approach, where not all clinicians were registered to use TOTO, led to negative consequences, including an increased risk of privacy and security breaches, and clinicians being automatically logged out mid-task while using a TOTO computer. Staff being protective of their computers, to avoid being logged out and having to log back in, was a key behaviour that TOTO-VD was intended to eradicate, facilitating computer switching and mobile work. Findings revealed that inconsistent use of TOTO, and the workarounds taken, were to avoid delays in the system rebooting when tapping back on, and the TOTO-VD system’s inconsistent performance. The system’s inconsistent performance and unexplained behaviours (e.g. unexpectedly logging the user off) were thus both the cause and the effect of users’ workarounds and inconsistent usage. Time savings have previously been demonstrated with SSO systems [ 5 , 6 , 9 , 10 ], and although potential time savings were raised by some participants in interviews, our study also revealed that this key benefit is unlikely to be realised until the variable performance and slow log-in process with TOTO-VD is rectified. This study adds to the growing body of work demonstrating that when technologies are implemented in real world contexts, they rarely work as designers envisioned [ 8 ]. The busy, time-pressured, nomadic and interrupted nature of work in the ED was expected to create conditions ripe for use of the TOTO-VD system, with the system envisioned as a solution to access control challenges posed by the nature of work in ED. However, observations revealed that these characteristics of clinical work acted instead as barriers to the use of the TOTO-VD system, largely because system speed could not keep up with the pace of work. The slow system reboot was also reported to have been affected by the automated opening of applications such as Teams, which appeared to be unnecessary in the ED context. Unlike research on SSO in general hospital areas, where users frequently accessed and switched between multiple applications [ 8 ], our study revealed that the bulk of work in the ED is done on EMRs. Our findings suggest that potentially more could have been done to understand how work is actually done in the ED, when and how computers are used and what systems are accessed (core activities of a human-centred design approach [ 15 ]), prior to implementation of the TOTO-VD system. Poor adoption of new technologies is also expected if the technologies interfere with workflows and are perceived to take time away from direct patient care [ 16 ], two findings that emerged from our interviews. TOTO-VD systems are intended to facilitate control of access to computer systems, which is paramount for security, auditing and accountability [ 4 ]. A challenge to access control in this case, however, was that clinicians perceived there to be redundant control of access, with no shared concern for patient privacy or security in the ED, prior to TOTO-VD implementation. Clinicians were observed to step away from the computer without tapping off (as in Figs. 3 and 4 ), a behaviour consistent with this belief. Furthermore, accountability of clinical actions was managed in other ways, via electronic signatures of orders. Both these factors resulted in users holding the view that stricter access control with TOTO-VD was unjustified or superfluous. The workarounds adopted by clinicians undermined the control of access put in place by the organization, and possibly increased security risks, and thwarted data quality, impacting auditing and accountability. Our results relating to a perception of increased privacy risks are consistent with those which have been identified with use of SSO [ 8 ], and suggest that TOTO and VD appear to heighten these security vulnerabilities, a key unintended consequence of implementation. These results were fed back to the health service and we made several recommendations based on our findings. In addition to system fixes, we recommended more computers be available to staff in the ED, and additional training be implemented for new users. As a result, a number of changes were made to the system and associated processes (Table 2 ), although these changes are yet to be evaluated. This direct translation highlights the value of investigating how work is actually performed in practice. Table 2. Improvements made to the tap on-tap off and virtual desktop system and associated processes, as a result of the research findings Issue targeted Changes made Inconsistent performance, including TOTO-VD downtimes • Ongoing technical improvements in system performance, resulting in increased speed and usability. E.g. Workaround for a limitation that allowed a maximum of 2000 staff to be connected at one time • A visiting clinician icon was developed and is available on all computers in the ED. It allows clinicians to manually access their EMR by logging in with their single sign on credentials Clinicians visiting the ED who are not registered with TOTO • The visiting clinician icon can be used by visiting clinicians to the ED who do not have access to TOTO, providing them with access to the EMR • All clinicians can request access to TOTO via an access request form, available on all computers via a QR code • Access is granted within 90 min of logging a request Open in a new tab TOTO = Tap on tap off; VD=virtual desktop; ED=Emergency Department; EMR=electronic medical record Strengths and limitations We complemented interviews with work observations, to understand how systems were actually used and functioned, but undertook only 7 h of observation, which unlikely captured the complexity of workflows and range of interactions possible with the TOTO-VD system. We also did not ensure all times of the day were captured during observations. Interviews were brief, preventing in-depth insights to be gained. We continued data collection until thematic saturation was reached, for both interviews and observations, and ensured rigour in our analysis and interpretation of data via team discussions and consensus processes, but the study was limited by the small sample size. Participants in the study may not have been representative of all staff in the ED, where approximately three times as many nurses work compared to doctors, and likely reflected those with a strong interest or feelings about the TOTO-VD system. This study was conducted in a single ED and findings may not be generalizable to other contexts or systems. Conclusions Work observations and interviews revealed that the tap on/tap off system with virtual desktop, did not support clinical work in an ED. The TOTO-VD system appeared to be incompatible with information needs and work practices in the ED and so was circumvented by users. Our findings indicated that for the TOTO-VD system to support clinical work in the ED, it must consistently function well, and all users need to be registered with TOTO. In the ED setting, a well-functioning TOTO would add some value, but there appears to be limited use for, and potentially new risks introduced, with the virtual desktop solution. Supplementary Information Below is the link to the electronic supplementary material. Supplementary Material 1 (17.6KB, docx) Acknowledgements The authors would like to thank Sebastian Adams, Marc Pelusi, Richard Taggart, James Newman and Chetankumar Mistry for their support of this project. We would also like to thank the University of Manchester for covering the journal publication fees. Abbreviations ED Emergency department EMR Electronic medical record SSO Single sign-on TOTO Tap-on-tap-off VD Virtual desktop Author contributions MB and AJ conceived of the study, ABA assisted with study design. KS, JOR and BAH collected the data, KS, ABA, JOR, BAH, VL and MB analysed the data. SL, CM, CJQ and OK assisted with study logistics and participant recruitment. All authors contributed to interpretation of findings and writing of the manuscript. Funding No funding was received for conducting this study. Data availability As per ethics approval, the qualitative data collected in this research can not be shared. Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical standards in the Declaration of Helsinki and approved by the Sydney Local Health District Human Research Ethics Committee. All participants gave written informed consent to take part. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Bardram JE. 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