Presentation
DH15 - Usability testing of clinical documentation features in an electronic health records system with inpatient nurses
DescriptionBackground: Several contributors to the clinical documentation burden have been identified in the literature, including broad usability issues with electronic health records (EHR) systems. However, it remains unclear how the usability of specific aspects of documentation features in the EHR influences this documentation burden, especially in inpatient settings and among nurses. To address this gap, we assessed the usability of key documentation features in an EHR system with acute and critical care nurses and explored how usability contributed to the clinical documentation burden in hospitals.
Methods: Data were collected from a semi-structured one-on-one interview and a usability survey, which were guided by a theoretical model of the Unifying Theory of Acceptance and Use of Technology. From June 2023 to August 2023, we interviewed 20 acute and critical care registered nurses at an academic medical center, which is located in Florida and uses the Epic EHR system. We focused on the use of five key nursing documentation features: 1) flowsheets, 2) medication administration records (MAR), 3) care plans, 4) nursing progress notes, and 5) admission-discharge-transfer navigators. Accordingly, we assessed perceived documentation burden, use of each of the five features, usability concerns, and areas for improvement. After the interview, we administered a survey that contained questionnaires covering usability, as measured by the System Usability Scale (SUS) and documentation burden for each of the five features, as well as demographics. The SUS is a validated instrument for assessing the usability of digital technology, including those in healthcare. Scores range from 0 to 100 with higher scores representing higher perceived usability. The average usability scores across healthcare and non-healthcare technology is 68.00. For interview data, we conducted a thematic content analysis and identified major themes. For survey data, we described our sample’s characteristics and the perceived documentation burden and average SUS scores per documentation feature.
Results: Most nurses (75.0%, n=15) in our sample had a bachelor’s degree in nursing, were full-time (90.0%, n=18), cared for more than two patients at a time (80.0%, n=16), and felt somewhat or very comfortable with digital technology (100.0%, n=20). Besides Epic, other EHR systems nurses had experience with were Cerner (40.0%, n=8) and MEDITECH (40.0%, n=8). Overall, nurses had varied perceptions of documentation burden from use of each of the five features, ranging from the MAR contributing the least to documentation burden and care plans contributing the most. Average SUS scores also varied immensely by documentation feature, ranging from 46.88 (SD:19.45; range:10-82.5; IQR:31.25) for care plans to 80.88 (SD:13.31; range:47.5-100.0; IQR:18.75) for the MAR. The average SUS scores also suggest that only the MAR and progress notes (75.63, SD:17.68; range:42.5-100.0; IQR:28.75) were higher than the published average usability score of 68.00. Key themes in usability issues included mismatches of vocabulary in the EHR and clinical practice, lack of an undo feature, unclear error messages that do not facilitate troubleshooting, and the display of information that is not clinically relevant to the nurse on the screen. Nurses felt these issues compounded their documentation burden by causing additional delays into their workflows in order for them to attempt to address usability problems. These issues, in part, led to the use of several workarounds, including documenting information in progress notes if it was unclear where it should go, providing the least amount of specific information necessary to better facilitate copy-and-paste, creating duplicate documentation due to lack of an “undo” button, changing the due times of events (e.g., bathing a patient, medications), and changing note types to improve the probability they will be read by the care team. Accordingly, nurses identified several usability-related improvements to the nursing documentation features, such as including the use of keyboard shortcuts during EHR training for quicker interface navigation, auto-completion features in search bars, having a shared on-site informatics nurse to provide at-the-elbow support to nurses, and visual cues and feedback to show what documentation has been completed versus not completed.
Conclusion: This study found that, among acute and critical care nurses, potential differences may exist in the perceived usability of several key nursing documentation features in the EHR. In response, nurses have developed and implemented workarounds to attempt to address usability issues. Our findings also suggest future directions for research to improve the usability of the EHR to improve human-computer interactions in the context of inpatient nursing care.
Acknowledgments: This study is supported by the University of Florida College of Nursing Internal Pilot Project (PI: Cho).
Methods: Data were collected from a semi-structured one-on-one interview and a usability survey, which were guided by a theoretical model of the Unifying Theory of Acceptance and Use of Technology. From June 2023 to August 2023, we interviewed 20 acute and critical care registered nurses at an academic medical center, which is located in Florida and uses the Epic EHR system. We focused on the use of five key nursing documentation features: 1) flowsheets, 2) medication administration records (MAR), 3) care plans, 4) nursing progress notes, and 5) admission-discharge-transfer navigators. Accordingly, we assessed perceived documentation burden, use of each of the five features, usability concerns, and areas for improvement. After the interview, we administered a survey that contained questionnaires covering usability, as measured by the System Usability Scale (SUS) and documentation burden for each of the five features, as well as demographics. The SUS is a validated instrument for assessing the usability of digital technology, including those in healthcare. Scores range from 0 to 100 with higher scores representing higher perceived usability. The average usability scores across healthcare and non-healthcare technology is 68.00. For interview data, we conducted a thematic content analysis and identified major themes. For survey data, we described our sample’s characteristics and the perceived documentation burden and average SUS scores per documentation feature.
Results: Most nurses (75.0%, n=15) in our sample had a bachelor’s degree in nursing, were full-time (90.0%, n=18), cared for more than two patients at a time (80.0%, n=16), and felt somewhat or very comfortable with digital technology (100.0%, n=20). Besides Epic, other EHR systems nurses had experience with were Cerner (40.0%, n=8) and MEDITECH (40.0%, n=8). Overall, nurses had varied perceptions of documentation burden from use of each of the five features, ranging from the MAR contributing the least to documentation burden and care plans contributing the most. Average SUS scores also varied immensely by documentation feature, ranging from 46.88 (SD:19.45; range:10-82.5; IQR:31.25) for care plans to 80.88 (SD:13.31; range:47.5-100.0; IQR:18.75) for the MAR. The average SUS scores also suggest that only the MAR and progress notes (75.63, SD:17.68; range:42.5-100.0; IQR:28.75) were higher than the published average usability score of 68.00. Key themes in usability issues included mismatches of vocabulary in the EHR and clinical practice, lack of an undo feature, unclear error messages that do not facilitate troubleshooting, and the display of information that is not clinically relevant to the nurse on the screen. Nurses felt these issues compounded their documentation burden by causing additional delays into their workflows in order for them to attempt to address usability problems. These issues, in part, led to the use of several workarounds, including documenting information in progress notes if it was unclear where it should go, providing the least amount of specific information necessary to better facilitate copy-and-paste, creating duplicate documentation due to lack of an “undo” button, changing the due times of events (e.g., bathing a patient, medications), and changing note types to improve the probability they will be read by the care team. Accordingly, nurses identified several usability-related improvements to the nursing documentation features, such as including the use of keyboard shortcuts during EHR training for quicker interface navigation, auto-completion features in search bars, having a shared on-site informatics nurse to provide at-the-elbow support to nurses, and visual cues and feedback to show what documentation has been completed versus not completed.
Conclusion: This study found that, among acute and critical care nurses, potential differences may exist in the perceived usability of several key nursing documentation features in the EHR. In response, nurses have developed and implemented workarounds to attempt to address usability issues. Our findings also suggest future directions for research to improve the usability of the EHR to improve human-computer interactions in the context of inpatient nursing care.
Acknowledgments: This study is supported by the University of Florida College of Nursing Internal Pilot Project (PI: Cho).
Event Type
Poster Presentation
TimeMonday, March 254:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives