Implementing Best Practices to Redesign Workflow and Optimize Nursing Documentation in the Electronic Health Record

Abstract

Background Documentation burden associated with electronic health records (EHR) is well documented in the literature. Usability and functionality of the EHR are considered fragmented and disorganized making it difficult to synthesize clinical information. Few best practices are reported in the literature to support streamlining the configuration of documentation fields to align clinical workflow with EHR data entry elements.

Objective The primary objective was to improve performance, reduce duplication, and remove nonvalue-added tasks by redesigning the patient assessment template in the EHR using best practice approaches.

Methods A quality improvement approach and pre-/postdesign was used to implement and evaluate best approaches to redesign standardized flowsheet documentation workflow. We implemented standards for usability modifications targeting efficiency, reducing redundancy, and improving workflow navigation. The assessment type row was removed; a reassessment section was added to the first three flowsheet rows and documentation practices were revised to document changes from the initial assessment by selecting the corresponding body system from the dropdown menu. Vendor-supplied timestamp data were used to evaluate documentation times. Video motion-time recording was used to capture click and scroll burden, defined as steps in documentation, and was analyzed using the Keystrok Level Model.

Results This study's results included an 18.5% decreased time in the EHR; decrease of 7 to 12% of total time in flowsheets; time savings of 1.5 to 6.5 minutes per reassessment per patient; and a decrease of 88 to 97% in number of steps to perform reassessment documentation.

Conclusion Workflow redesign to improve the usability and functionality decreased documentation time, redundancy, and click burden resulting in improved productivity. The time savings correlate to several hours per 12-hour shift which could be reallocated to value-added patient care activities. Revising documentation practices in alignment with redesign benefits staff by decreasing workload, improving quality, and satisfaction.

Keywords

flowsheets - patient reassessment - documentation burden - electronic health records - workflow evaluation - redesign - nursing

Protection of Human and Animal Subjects

Protection of Human and Animal Subjects Human and/or animal subjects were not included in this project.

Publication History

Received: 04 January 2022

Accepted: 01 June 2022

Accepted Manuscript online:
03 June 2022

Article published online:
20 July 2022

• References

• 1 Ommaya AK, Cipriano PF, Hoyt DB. et al. Care-centered clinical documentation in the digital environment: solutions to alleviate burnout. Accessed June 15, 2022 at: https://nam.edu/wp-content/uploads/2018/01/Care-Centered-Clinical-Documentation.pdf
• 2 Ashton M. Getting rid of stupid stuff. N Engl J Med 2018; 379 (19) 1789-1791
• 3 OʼBrien A, Weaver C, Settergren TT, Hook ML, Ivory CH. EHR Documentation: The hype and the hope for improving nursing satisfaction and quality outcomes. Nurs Adm Q 2015; 39 (04) 333-339
• 4 Collins S, Couture B, Kang MJ. et al. Quantifying and visualizing nursing flowsheet documentation burden in acute and critical care. AMIA Annu Symp Proc 2018; 2018: 384-357
• 5 Ehrenfeld JM, Wanderer JP. Technology as friend or foe? Do electronic health records increase burnout?. Curr Opin Anaesthesiol 2018; 31 (03) 357-360
• 6 Higgins LW, Shovel JA, Bilderback AL. et al. Hospital nurses' work activity in a technology- rich environment: a triangulated quality improvement assessment. J Nurs Care Qual 2017; 32 (03) 208-217
• 7 Momenipur A, Pennathur PR. Balancing documentation and direct patient care activities: A study of a mature electronic health record system. Int J Ind Ergon 2019; 72: 338-346
• 8 Tan M, Lipman S, Lee H, Sie L, Carvalho B. Evaluation of electronic medical records on nurses' time allocation during cesarean delivery. J Patient Saf 2019; 15 (04) e82-e85
• 9 Nation J, Wangia-Anderson V. Applying the data-knowledge-information wisdom framework to a usability evaluation of electronic health record system for nursing professionals. Accessed September 10, 2021 at https://www.himss.org/resources/applying-data-knowledge-information-wisdom-framework-usability-evaluation-electronic-health-record
• 10 Nelson R. Nurses' dissatisfaction with electronic health records remains high. Am J Nurs 2016; 116 (11) 18-19
• 11 Wisner K, Lyndon A, Chesla CA. The electronic health record's impact on nurses' cognitive work: an integrative review. Int J Nurs Stud 2019; 94: 74-84
• 12 Sutton DE, Fogel JR, Giard AS, Gulker LA, Ivory CH, Rosa AM. Defining an essential clinical dataset for admission patient history to reduce nursing documentation burden. Appl Clin Inform 2020; 11 (03) 464-473
• 13 Sengstack P. A tipping point? Documentation in the EHR. National efforts toward improvement. Accessed June 15, 2022 at: https://bigdata.dreamhosters.com/sites/default/files/2021-04/A%20Tipping%20Point%20Documentation%20in%20the%20EHR%20%E2%80%93National%20Efforts%20Toward%20Improvement%20.pdf
• 14 American Nurses Association. ANA's principles for nursing documentation: guidance for registered nurses. Accessed June 15, 2022 at: http://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf
• 15 Harrington L. Copy-forward in electronic health records: lipstick on a pig. Jt Comm J Qual Patient Saf 2017; 43 (08) 371-374
• 16 Karp EL, Freeman R, Simpson KN, Simpson AN. Changes in efficiency and quality of nursing electronic health record documentation after implementation of an admission patient history essential data set. CIN: computers, informatics. Comput Inform Nurs 2019; 37 (05) 260-265
• 17 EPIC. . (2019). Executive packet: Duke University Health System [Data set]
• 18 EPIC. . (2020). Executive packet: Duke University Health System [Data set]
• 19 EPIC. . (2021). Executive packet: Duke University Health System [Data set]
• 20 Saitwal H, Feng X, Walji M, Patel V, Zhang J. Assessing performance of an electronic health record (EHR) using cognitive task analysis. Int J Med Inform 2010; 79 (07) 501-506
• 21 Johnson CM, Johnston D, Crowley PK. et al. EHR usability toolkit: a background report on usability and electronic health records (Prepared by Westat under Contract No. 290–09–00023I–7). AHRQ Publication No. 11–0084-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2011
• 22 Talmon J, Ammenwerth E, Brender J, de Keizer N, Nykänen P, Rigby M. STARE-HI–Statement on reporting of evaluation studies in Health Informatics. Int J Med Inform 2009; 78 (01) 1-9
• 23 Oosterwijk H. Determining the measures of success for interoperability. HIMSS. Accessed September 10, 2021 at: https://www.himss.org/resources/determining-measures-success-interoperability
• 24 Gesner E, Gazarian P, Dykes P. The burden and burnout in documenting patient care: an integrative literature review. Stud Health Technol Inform 2019; 264: 1194-1198
• 25 Moy AJ, Schwartz JM, Chen R. et al. Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. J Am Med Inform Assoc 2021; 28 (05) 998-1008
• 26 Rosetti SC, Rosenblum T, Johnson K. 25 by 5: Symposium to reduce documentation burden on U.S. clinicians by 75% by 2025. Accessed June 15, 2022 at: https://www.dbmi.columbia.edu/wp-content/uploads/2021/01/25x25-Symposium-Intro.pdf
• 27 Boyle DK, Baernholdt M, Adams JM. et al. Improve nurses' well-being and joy in work: Implement true interprofessional teams and address electronic health record usability issues. Nurs Outlook 2019; 67 (06) 791-797
• 28 Strudwick G, McGillis Hall L, Nagle L, Trbovich P. Acute care nurses' perceptions of electronic health record use: a mixed method study. Nurs Open 2018; 5 (04) 491-500
• 29 Weir CR, Staes C, Slager S. et al. What are they trying to do? An analysis of action identities in using electronic documentation in an EHR. AMIA Annu Symp Proc 2017; 2017: 1764-1772
• 30 Kutney-Lee A, Brooks Carthon M, Sloane DM, Bowles KH, McHugh MD, Aiken LH. Electronic health record usability: associations with nurse and patient outcomes in hospitals. Med Care 2021; 59 (07) 625-631
• 31 U.S. General Services Administration. Usability evaluation basics. Accessed. December 22, 2021 at: https://www.usability.gov/what-and-why/usability-evaluation.html
• 32 Rule A, Chiang MF, Hribar MR. Using electronic health record audit logs to study clinical activity: a systematic review of aims, measures, and methods. J Am Med Inform Assoc 2020; 27 (03) 480-490