EHR usability and usefulness, perceived missed nursing care and medication errors in critical care

Student summary

Why This Research Matters

This article introduces a significant funded research project (NIH grant 5R01HS029011-05) focused on understanding how Electronic Health Records (EHRs) affect nurses in critical care settings. The core problem addressed is that EHR systems, while intended to improve patient safety and quality of care, can create substantial burdens for nurses. Evidence suggests that a large percentage of nurses are dissatisfied with their use of these systems due to factors like time demands, complexity, and concerns about the impact on actual patient outcomes such as missed nursing care or medication errors.

The project's main goal is to comprehensively evaluate EHR usability (how easy it is to use) and usefulness (how beneficial it is for nurses). It proposes a 5-year study that will be conducted across multiple hospital sites. This mixed-methods approach means the researchers will gather data using various techniques, not just one type of measurement.

The first aim is to understand EHR usability and usefulness from both micro-level perspectives (like individual nurse interactions) and macro-level perspectives (broader system impacts). They plan to do this by mapping out how nurses actually use the EHR in their clinical workflow. This involves analyzing data generated by the EHR itself, such as time stamps of activities or sequences of tasks performed within the EPIC system (a common hospital software platform mentioned here). Structured interviews with nurses will provide qualitative insights into their experiences and challenges. Targeted observations of nurses using the EHR in real-time will offer direct behavioral data. Surveys will be used to gather broader opinions from a larger group of nurses, covering aspects like functionality and interoperability (how well different parts of the system work together).

The second aim is to measure real-time usability with mobile monitoring technology. This involves using eye-tracking glasses worn by nurses as they interact with the EHR at their bedside or workstation. These glasses can record where a nurse looks on the screen, how long they look at specific elements, and what actions they take in response. The data collected from these glasses will be time-stamped to correlate visual attention patterns with actual tasks performed within EPIC. Following this monitoring period, cognitive interviews will be conducted with nurses to delve deeper into their thought processes, challenges encountered during EHR use, and the decisions made while navigating the system.

The third aim is to examine how EHR usability and usefulness directly impact nurse-perceived patient safety outcomes. This means looking at whether improvements in EHR design or ease of use lead to fewer instances of nurses feeling they have missed essential care tasks (missed nursing care) or making medication errors, which can be life-threatening. The study will account for various dimensions of nursing workload that might influence these perceptions and outcomes. These dimensions include cognitive load (mental effort required), physical demands (e.g., typing speed, screen positioning), and temporal pressure (time constraints). By considering these factors alongside EHR use, the researchers aim to build a more complete picture of how technology interacts with human performance in high-stakes environments.

Finally, the study includes a proactive risk analysis component. This involves selecting three key clinical nursing workflow processes that are heavily supported by the EHR and systematically identifying potential vulnerabilities or points where errors could occur within these workflows. The goal here is to anticipate problems before they lead to actual patient harm.

For students of nursing research, this project highlights several important aspects. It demonstrates how complex healthcare issues like technology implementation can be addressed through rigorous, multi-faceted research designs that combine quantitative and qualitative methods. Understanding the proposed methodology helps in appreciating the challenges involved in studying human-computer interaction in clinical settings. Students should appraise the study's potential to generate actionable insights for improving EHR systems and nursing practice, thereby enhancing patient safety.

It is crucial to remember that this document is a project abstract or proposal; it outlines what researchers plan to do rather than reporting findings from completed work. Therefore, claims about specific outcomes (e.g., exact sample sizes, measured statistics) are not present in the provided metadata and should not be inferred. The focus here is on the planned investigation.

When considering source rights and usage, this record comes from NIH RePORTER, which provides public project metadata for funded research projects. While it offers valuable information about the study's aims and methods, direct access to the full text of the proposal or final published findings (if any) might require further steps depending on how the funding agency makes its outputs available. The copyright notice indicates that NIH RePORTER itself holds certain rights over this metadata presentation.

A nurse reasoning from potential evidence generated by such a study would consider several things. If, for instance, eye-tracking data showed nurses frequently getting lost in complex navigation paths within the EHR during critical tasks (like medication administration), or if surveys consistently indicated high cognitive load associated with specific modules of the system, this would point to areas needing redesign. Similarly, if risk analysis identified a particular workflow step as prone to errors due to poor interface design at that juncture, targeted improvements could be made there.

The ultimate goal for nurses is an EHR system that supports their work effectively without adding undue burden or increasing the risk of patient harm. This research aims to provide evidence-based insights into how such systems can be better designed and implemented.

Faculty notes

Educational Relevance

This NIH-funded research project (5R01HS029011-05) addresses a critical issue in modern healthcare: the impact of Electronic Health Record (EHR) usability on nursing practice, particularly concerning patient safety outcomes like perceived missed nursing care and medication errors. The abstract outlines a comprehensive 5-year mixed-methods field study designed to understand EHR burden from multiple angles.

The research is driven by evidence that nurses dedicate approximately one-third of their direct patient care time interacting with the EHR, yet there's significant dissatisfaction among this population regarding its use, perceived burden, and impact on quality and safety. This project aims to fill a gap in existing literature which often examines isolated aspects of usability or fails to robustly link nurse experiences directly to tangible outcomes.

The study is structured around three primary aims: 1. To comprehensively evaluate EHR usability and usefulness through micro- (individual interactions) and macro-level measures. This includes process mapping of clinical workflows, analysis of EPIC system data (time stamps, task sequencing), structured interviews with nurses about their experiences, targeted observations of EHR use in practice settings, and nurse surveys covering aspects like functionality and interoperability. 2. To measure real-time usability using mobile monitoring technology—specifically eye-tracking glasses worn by nurses while interacting with the EPIC system at the bedside or workstation. This data will be time-stamped to correlate visual attention patterns (e.g., where a nurse looks, how long they fixate on elements) with actual tasks performed within the EHR. Following this period of monitoring, cognitive interviews will be conducted to gain deeper insights into nurses' thought processes, challenges encountered during EHR use, and decision-making related to system navigation. 3. To examine the impact of EHR usability and usefulness on nurse-perceived patient safety outcomes (missed nursing care, medication errors). This analysis will account for various dimensions of nursing workload—cognitive load, physical demands associated with using the technology, and temporal pressures—to understand how these factors interact with EHR use.

Additionally, a proactive risk analysis component is planned to identify potential vulnerabilities within three key clinical nursing workflow processes that are heavily reliant on the EHR. This aims to anticipate threats before they lead to patient harm.

The study's multi-site design and mixed-methods approach are significant strengths for generalizability and depth of understanding. The use of eye-tracking glasses offers a novel way to capture real-time user behavior, potentially revealing usability issues that might not be apparent through self-reporting alone (e.g., cognitive overload or inefficient navigation patterns). However, as with any research proposal at this stage, limitations are inherent in the planned design rather than observed outcomes. These include potential selection bias if participating sites are not representative of all critical care environments, challenges in generalizing findings from specific EPIC implementations to other EHR systems, and reliance on 'perceived' missed nursing care/medication errors which can be subject to recall or reporting biases.

The clinical relevance is high. Findings could directly inform the design of more user-friendly EHR interfaces tailored for critical care settings, potentially reducing nurse burnout and improving adherence to safety protocols. Insights from real-time monitoring might highlight specific areas within the EPIC system that require redesign or additional training support. Understanding how different workload dimensions interact with EHR use can guide the development of better workflow strategies or staffing models. The risk analysis could pinpoint systemic issues within clinical workflows supported by EHRs, allowing for targeted interventions to enhance patient safety.

For faculty and students in nursing research, this project serves as an excellent example of a well-structured proposal addressing a pertinent problem using contemporary methodologies. It underscores the importance of human factors engineering principles in healthcare technology design. Students should critically appraise such proposals by considering the rigor of the methodology, potential biases, feasibility, and how findings might be translated into practice. The distinction between research aims (what is planned) and actual study results (which are not yet available from this abstract alone) must always be maintained.