Electronic Health Record Usability and Documentation Burden in Acute and Critical Care: A Mixed-Methods Study (Preprint)
Authors: CHO HWAYOUNG , Nguyen Oliver T. , Weaver Michael , Pruitt Jennifer , Marcelle Cassie , Salloum Ramzi G. , Keenan Gail 
Published: December 2023

BACKGROUND

There is ample evidence that not all components of electronic health record (EHR) systems work as intended. Testing the user interface and workflow design of every EHR component does not adequately consider the needs of users in the clinical workflow. This has led to negative end-user outcomes including documentation burden, leading to adverse effects on patient outcomes. Nurses who provide the majority of frontline care for hospitalized patients are disproportionately affected by the current state of EHR systems, and little is known about their lived experience using EHR. We sought the input of nurses in real-world practice to understand everyday user experience with EHRs including the strengths and barriers to documentation.

OBJECTIVE

To examine nurses’ current EHR use and identify factors that could contribute to the documentation burden in acute and critical care units at a large academic medical center.

METHODS

An explanatory sequential mixed-methods research design was used to explore nurses’ current use of the key components of an EHR, Flowsheets, Medication Administration Records (MAR), Care Plan, Notes, and Admission-Discharge-Transfer (ADT) navigators, using log file analyses, one-on-one interviews, and surveys. We first conducted analyses of Epic usage log file data to identify acute and critical care units in which the nurse documentation burden could be the highest. We then explored nurse perceptions of ease of use and usefulness of the EHR components with a convenience sample of 20 nurses from the five identified units via interviews and surveys. Guided by the Unified Theory of Acceptance and Use of Technology (UTAUT) framework, we conducted an in-depth analysis and synthesis of data from log files, interviews, and surveys and assessed factors contributing to the nurse documentation burden.

RESULTS

Our study showed that nurses acknowledged the importance of documentation at the point of care and its meaningfulness to patient care, yet perceived required documentation as being burdensome producing documentation-related stress. Overall, nurses reported varied levels of documentation burden stemming from each EHR component. Possible factors contributing to the documentation burden included general barriers such as high patient-to-nurse staffing ratios, patient acuity, and suboptimal time management, and usability issues related to the design and features (i.e., functionality, flexibility, customizability) of the EHR components. Three EHR components, Flowsheets, Care Plan, and ADT Navigators, were found to be below the acceptable usability score range and contributed more to the documentation burden as compared to MAR and Notes. As actionable strategies, providing “contextual autocomplete” features that can rank concepts by predicted probability and adding a search bar to be used for their needed information and decision-making into each component could assist the nurse with data entry using standard terminologies and also facilitate guiding nurses to document in similar situations using technology-based tools.

CONCLUSIONS

Our study generated evidence for nurses’ current patterns of EHR use and identified specific issues with documentation contributing to burden. Findings from this study can inform solutions for enhancing the usability of multi-component EHR systems by reducing redundancy, improving workflow navigation, advancing autocompleted data entry, and addressing individual and organizational factors to mitigate the nurse documentation burden.