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Use of Electronic Health Record Documentation by Healthcare Workers in an Acute Care Hospital System Daleen Aragon Penoyer, PhD, RN, director. Center for Nursing Research, Orlando Health, Orlando, Florida; Kendall H. Cortelyou-Ward, PhD, assistant professor. Health Management and Informatics, University of Central Horida, Orlando; Alice M. Noblin, PhD, assistant professor. Health Management and Informatics, University of Central Florida; Tim Bullard, MD, medical chief Business Development à Innovation, Orlando Health; Steve Talbert, PhD, RN, assistant clinical professor. College of Nursing, University of Central Florida; Jason Wilson, RN, healthcare consultant, CIC Advisory, Tampa, Florida; Beatrice Schafhauser, RN, manager. Clinical Informatics, Orlando Health; and Joshua G. Briscoe, MD, physician. Emergency Physicians of Central Florida, Orlando

E X E C U T I V E S U M M A R Y Acute care clinicians spend significant time documenting patient care information in electronic health records (EHRs). The documentation is required for many reasons, the most important being to ensure continuity of care. This study examined what information is used by clinicians, how this information is used for patient care, and the amount of time clinicians perceive they review and document information in the EHR. A survey administered at a large, multisite healthcare system was used to gather this information.

Findings show that diagnostic results and physician documents are viewed more often than documentation by nurses and ancillary caregivers. Most clinicians use the information in the EHR to understand the patient's overall condition, make clini- cal decisions, and communicate with other caregivers. The majority of respondents reported they spend 1 to 2 hours per day reviewing information and 2 to 4 hours documenting in the EHR. Bedside nurses spend 4 hours per day documenting, with much of this time spent completing detailed forms seldom viewed by others. Various now sheets and forms within the EHR are rarely viewed.

Organizations should provide ongoing education and awareness training for hospital clinical staff on available forms and best practices for effective and efficient documentation. New forms and input fields should be added sparingly and in col- laboration with informatics staff and clinical team members to determine the most useful information when developing documentation systems.

For more information about the concepts in this article, contact Dr. Penoyer at [email protected].

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INTROOUCTION Documentation in the medical chart originally served to provide a record of a patient's care and to improve com- munication among healthcare provid- ers. As medical records have evolved into true health records, documenta- tion has come to serve many purposes, such as evidence for medical legal cases, required backup for reimbursement, and information for developing measures for quality and regulatory purposes. This expansion requires clinicians to spend increased time and effort documenting the care provided, with the unintended consequence that they potentially spend less time providing direct patient care.

Study findings demonstrate that nurses have mixed perceptions about the electronic health record (EHR): It is extensive but time consuming (Saarinen & Aho, 2005; Scott, Rundall, Vogt, & Hsu, 2005); it helps and hinders nursing work (Kossman & Scheidenhelm, 2008; Hakes & Whittington, 2008; Dennis, Sweeney, Macdonald, & Morse, 1993); and it has both positive and negative effects on patient care (Koppel et al., 2005; Han et al., 2005; Fraenkel, Cowie, & Daley, 2003; Mekhjian et al., 2002). In one study, 73% of nurses reported spending at least 50% of their time using the EHR, which leaves less time for patient care (Kossman & Scheiden- helm, 2008). Some nurses reported that their critical thinking is reduced by using the EHR, but most nurses believed that its benefits outweigh its drawbacks (Moody, Slocumb, Berg, & Jackson, 2004; Fraenkel et a l , 2003).

Most research to date has looked specifically at the time and burden associated with documenting in an

EHR. Few studies report clinician use of information from the EHR. Qur aim was to determine what information from the EHR is viewed and how that information is used by different types of clinicians.

B A C K G R O U N D To guide discussion of the concepts, the structure-process-outcome (SPO) framework of Donabedian (1988) is used. According to Donabedian, struc- ture refers to the settings in which care occurs, including equipment and facili- ties; process includes what is actually done in healthcare activities; and out- come is the impact of care on the health status of a population. This framework describes our approach to examining how a variety of healthcare clinicians use data and information documented in the EHR at a multihospital system. Figure 1 demonstrates the use of this model for the study, and each SPO step is explained further in the following paragraphs.

Structure The EHR represents the structure for the documentation of healthcare in this study. This documentation provides the basis for patient care decisions. Clini- cal practitioners regularly contribute a great deal of information and data to the record to complete a multitude of tasks. For example, nurses record the patient's condition, care given, measure- ments taken, and medication adminis- tered through menu-driven checklists of nursing diagnoses, human body systems, and common patient problems. Although viewed as a time-saver by some nurses (Kossman & Scheidenhelm,

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F i G U R E 1 Structure-Process-Dutcome Quaiity iVIeasurement iVIodei

EHR • Interactions ' Decisions

2008), the drop-down menu options for nursing documentation may lack the detail needed by physicians for a complete picture of the patient's physical and psychosocial status (Kelley, Brandon, & Docherty, 2011). Therefore, nurses may need to provide additional free tejrt to fully describe a patient's clinical picture.

Process The process is clinicians' interactions with the EHR, including communica- tion among practitioners, how docu- mentation is completed, and time spent in doing so. Hripcsak, Vawdrey, Ered, and Bostwick (2011) report that 80% of nurses' notes go unread by physi- cians. Increased verbal communication between physicians and nurses often accounts for this lack of reading (Hripc- sak et al., 2011; Brown, Borowitz, & Novicoff, 2004). Clinicians appreciate the convenience of conversations and the use of a bedside fiow sheet to obtain necessary patient information. During nurse shift changes, a combination of verbal and written communication is preferred and considered most efficient for handoffs (Street et al., 2011).

In terms of time spent reviewing and documenting in the EHR, Likourezos et al. (2004) surveyed physicians and nurses at a large, urban, teaching hos- pital emergency room and discovered that nurses believed they were able to complete their work faster with the EHR than physicians thought they could complete their own work. Inpatient care nurses have also perceived time sav- ings with the EHR (Dennis et al., 1993; Moody et al., 2004; Banner & Olney, 2009; Bosman et al., 2003; Fraenkel et al., 2003).

Outcome The outcome measures for this study were related to how EHR information was used by practitioners to make deci- sions regarding patient care issues. These frequently include reviewing the docu- mentation of other clinicians, evaluating the patient's response to treatment, and understanding the patient's overall clini- cal picture. For example, the availability of previous history and physical docu- mentation has been shown to lead to better decision making regarding patient readmissions (Ben-Assuli, Leshno, & Shabtai, 2012). However, patient-level

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outcomes were beyond the scope of this project.

In this study, we sought to answer the following questions related to the use of the EHR in the clinical setting:

1. Which parts of the EHR do clinical practitioners access to view documented information?

2. How do clinical practitioners use information from the EHR in their practice?

3. What information from the EHR are practitioners using when caring for patients?

4. What is the perception of the amount of time clinical practitioners spend reviewing documentation in the EHR?

5. What is the perception of the amount of time clinical practitioners spend documenting in the EHR?

METHODS We administered a descriptive and exploratory online survey to a conve- nience sample of clinical practitioners at a large, six-facility community hos- pital system in the southeastern United States. The study population included clinical practitioners and caregivers who accessed, used, or contributed infor- mation to patients' EHRs, including physicians/providers, bedside nurses, managers/educators, medical/nurse assistants, advanced clinical nurses, ancillary professionals, discharge plan- ners/social workers, and ancillary diag- nostic personnel. Excluded from this study were team members who were not clinical practitioners, did not interface with the patient for a clinical purpose

or service, did not use or document data in patients' EHRs for patient care, and worked in outpatient diagnostic areas.

At the study organization, the EHR had been implemented incrementally over the course of the prior decade, starting with availability of diagnostic results (2004), nursing documenta- tion (2005-2007), and physician order entry (2008). Gradual increases in adoption and use of various compo- nents were seen, which were integrated and expanded to a number of areas in the organization. At the time of the study, the inpatient (IP) and emergency department (ED) units were fully inte- grated into the current EHR and thus were the only areas of the organization that participated in the study.

The survey instrument underwent a series of rigorous assessments and itera- tions by our multidisciplinary investiga- tive team. To assess for face validity, the instrument was distributed to key clini- cal experts, leaders, and users of clinical documentation across disciplines. Evalu- ators were asked to assess for burden of completion, relevancy of documentation used in practice, clarity of the questions, and feasibility of survey items. We used the feedback and input from all reviews to make final revisions to the survey.

We received approval from the study organization's nursing research coun- cil and institutional review board. The online survey was open for participation from November 1, 2011, to December 20, 2011. We used SPSS version 19 (IBM, 2010) to analyze all data.

RESULTS In total, 837 healthcare practitioners accessed the online survey. Of those.

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9 did not consent to participate in the study, leaving 828 surveys. Eighty sur- veys were blank, leaving 748 possible surveys for analysis. Nineteen surveys were less than 80% completed and were eliminated. We then eliminated those surveys completed by individuals whose role types were ineligible for inclusion, leaving 700 total usable surveys.

To determine the number of poten- tial subjects who would be eligible to join the study, we applied several filters to the approximately 14,000 team members from the study organiza- tion's human resources database. We used specific job codes for roles, hos- pitals, and unit locations that would meet inclusion. Applying those crite- ria, the number of eligible IP and ED team members was 6,664. Qur sample represented approximately a 10.5% response rate based on this assessment. Of those, 591 subjects were from the IP setting and 109 were ftom the ED. Data on EHR usage by subjects from the ED were analyzed separately from IP find- ings because of the differences in pace, priorities, and patient flow. Because fewer types of providers are actively involved in ED patient care, providers were grouped as prescribers (MDs, nurse practitioners, or physician assistants), nurses, and ancillary staff in this sub- analysis. Table 1 summarizes the total sample in the study.

Sample Characteristics The sample of 591 subjects from the IP setting consisted primarily of women (78.3%) and individuals who had achieved a baccalaureate degree or higher education (75.8%). The average age of the participants was

41.49 years; the youngest respondent was 19, and the oldest was 71. The sample also reflected an average tenure of 14.6 years in participants' role and 8.59 years' longevity with the organiza- tion. The primary role represented in the sample was bedside nurses (40%), fol- lowed by ancillary clinical roles (19%).

Study Question Results

Which parts of the EHR do clinical practitioners access to view documented information? An analysis of IP results was performed in 50 specific areas of the EHR to determine which areas are most often reviewed during patient care. We found that Diagnostic Results was the most frequently accessed (89%) by all provid- ers, with 96% of advanced clinical nurse professionals accessing this screen often or ftequently. Physicians Orders was also heavily used to review information, with 86% of respondents often or frequently accessing this portion of the record. Two forms of provider core documents heavily accessed were History and Physi- cal by a Physician (84%) and Physician Progress Notes (83%), while the Nurs- ing Care documents and Patient Work List were less frequently viewed by all subjects; only 63% of respondents indi- cated that they view this area regularly, of whom 90% of bedside nurses and 7% of prescribers access this area of the EHR for review. Table 2 summarizes the parts of the EHR that subjects reportedly review often in their role.

In contrast, many other areas of the EHR were less frequently accessed for review. Numerous nursing and ancillary core documents were rarely reviewed.

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TABLE 1 EHR Study Participant Characteristics

Characteristic

Age in years Years in role Years at facility

Gender Female Male No response

Education No formal degree Associate degree/diploma Baccalaureate degree Master's degree Doaorate

Role Prescribers Bedside nurses Ancillary clinical roles Managers/leaders Nursing/medical assistants Advanced clinical nurse Discharge planner Ancillary diagnosticians

(iV=700)

inpatient (/; = 591)

Average (Range)

42.49 (19-71) 14.61 (0-45) 8.59 (0-38)

Percent 7 8 % 19%

2 %

2 2 % 4 1 % 16%

19%

14% 4 1 % 19% 14%

2 %

4 % 4 % 2 %

"All ancillary roles combined into one category for the ED.

Emergency Department (/i=109)

Average (Range)

40.84 (24-60) 13.23 (1-47) 7.52 (0-26)

Percent 6 7 %

3 3 % —

2 6 % 2 4 %

16% 3 4 %

3 8 % 4 6 % 16%^

n/a n/a n/a n/a n/a

and many respondents indicated they did not know what they were. Table 3 summarizes some key documentation areas and the reported frequency of access to those areas.

Various existing clinical summary tabs within the EHR were also evalu- ated for access. With input from clinical

practitioners in different disciplines, team members from the informatics department developed and incorpo- rated integral components of the EHR into these summaries to provide an overall summary of important clinical information in one snapshot view. We found that the nursing general clinical

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T A B L E 2 Parts of the EHR IVIost Frequently Viewed, by Roie (%) (/i = 591)

Advanced Documentation Bedside Ciinlcal Anciiiary Discharge

Type Prescriher RN Manager Nurse Caregivers Planners Ail

Diagnostic Results Physician Orders History and

Physical Physician Progress

Notes Patient Work List

81 96

94 85

83 74

88 100

100

84 85

81 92

86 84

summaries were often or frequently reviewed 57% of the time by all groups, and 60% by bedside nurses. The sum- mary version developed for physicians was accessed frequently by 23% of prescribers; medication summaries were reportedly viewed by 65% ofthat group.

How do clinical practitioners use information from the EHR in their practice? Respondents were asked how they use the information they review in the EHR. The results showed that prescrib- ers (95%) and bedside registered nurses (RNs) (86%) most commonly used the information to make clinical decisions for the patient, while diagnostic profes- sionals rarely (15%) used information for this purpose. The most common reason to access the information was to gain an understanding of the overall condition of the patient (84%), and the least common reason was for review and

sign-off purposes (19%). Table 4 lists reasons for access by type of clinician.

What information from the EHR are practitioners using when caring for patients? Respondents were provided a list of common data elements in the EHR and asked which elements were most important to them when caring for a patient. Results from subjects in the IP group indicated that Vital Signs, Weight/ Height/BMI, and Diagnostic Tests (51%) were perceived as most important by all roles, closely followed by History (50%). These results were consistent among prescribers (58%), bedside RNs (56%), advanced clinical nurse practi- tioners (64%), and discharge planners (92%), all of whom noted that these data elements were important when providing care to patients. The diagnos- tic professionals indicated that none of these data elements were important to their provision of care. Low responses

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TABLE 3 Parts of the EHR Least Frequently Viewed

Documentation Type

Plan of Care Nursing Assessment Patient Education Restraint Use Discharge Assessment Patient Screenings

Braden Score Vaccines Falls Risk Pain Tuberculosis

Ancillary Caregiver Progress Notes Pharmacy Nutrition Respiratory Therapy Wound Manager Rehabilitation/PT Spiritual Care

by Clinical Practitioners (%) (/; = 591)

Percentage Reviewed Often by All Groups

3 8 3 3 22 41

35 22 30 4 6 2 3

15 19 21 2 6 2 3 21

Percentage Reviewed Often by Prescribers

7 4

5 1

2 11 1

13 5

12 18 10 25 20 8

for usefulness (20% or less overall) were found for patient education; nutritional, mobility, or respiratory status; ancillary reports; language and culture; and peri- operative events.

How much time do clinical practitioners spend reviewing documentation? Subjects were asked to estimate how much time they spend reviewing already documented information in the EHR. Answers for selection were provided in 0.5-hour increments; thus, mean values were not calculated. Results from the IP participants indicate

that 42% of the sample spend an hour or less reviewing documentation, while 15% spend 2.5 hours or more. Discharge planners reported that they dedicate the most time to record review, with 37% indicating that they spend between 3 and 4.5 hours a day review- ing. More than half of the prescribers and bedside RNs reported spending 1.5 hours or less per day reviewing docu- mentation. Figure 2 demonstrates the results from perceived number of hours per day spent reviewing versus hours perceived spent documenting for IP clinicians.

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How much time do clinical practitioners spend documenting? The perceptions regarding the amount of time spent documenting provide insight into the workload for each role in the organization. Answers for selection were provided in 0.5-hour increments; thus, mean values were not calculated. Wide variation in the amount of time spent authoring documentation was found across both the IP and ED settings. Bedside RNs reported the largest burden of documenting, with 62% of respon- dents indicating that they document more than 3 hours per day. This group is followed by prescribers, of whom 40%

indicated that they document more than 3 hours per day. Managers perceived that they spend the least amount of time documenting, with 59% reporting that they document 1 hour or less per day.

To evaluate and better understand the impact that type of unit and team member work location can have on the perceived differences in time spent reviewing and documenting, we sub- categorized respondents by work area. We found no statistically significant difference among the amount of time spent reviewing or documenting in the EHR between five subcategories: ancil- lary, critical care, step-down, medical/

TABLE 4 Inpatient Clinician Use ot Information Accessed

Make clinical decisions for patient

Evaluate response to treatment

Review other disciplines' documentation

Understand plan of care Understand overall condition Effectively communicate

and collaborate Leam more about patient Plan for discharge Regulatory requirements Review and sign off Patient medication list To give report Order clarification

Prescribers

68 83 81

58 11

2 8 4 6 1Ö 20

From tiie EHR |

RN-Bedside

75 85 82

80 56 2 5

2 5 49 52 44

Ancillary

79 9 4

39 8

36 15 56

Discharge Planners

81 89 96

62 92 37 12

46 4

Overall

72 84

51 21

19 39 2 8 34

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F I G U R E 2 Perceived Numher of Hours per Day Spent by IP Clinicians Reviewing Components in the EHR and Documenting in the EHR

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

— Hours Reviewing ~~»— Hours Documenting

surgical, and perioperative/procedural areas in the IP settings.

Additional Emergency Department Results In addition to the results reported here, 109 surveys were received from personnel in the ED. These findings mimicked those of the IP staff, but we found sufficient differences in the way the EHR is used in the ED to warrant their exclusion ftom the primary data. However, some interest- ing data were obtained ftom this analysis (available upon request ftom the corre- sponding author). Of particular interest is the high usage of the clinical résumé by ED prescribers (95%) and nurses (64%).

D I S C U S S I O N In this research, clinical practitioners' perceptions on which areas of the EHR they access for review (structures), how

that information is used (processes), and which components are useful for delivering patient care (outcomes) were explored. Most of the findings relate to the structures accessed in the EHR and the processes by which the information is used. For purposes of this study, the perception of usefulness of components when delivering patient care was the type of outcome we explored.

The structures within the EHR include the discrete data elements for documentation and specific areas within the record, such as assessments and diagnostic results. While these structures were routinely used for documenta- tion by many clinicians in all settings, their use for review and for making clinical decisions varied significantly. Other structures within the EHR include special views where summary reports are generated. Surprisingly, these findings

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showed that clinical summaries were not used to their highest potential by the various disciplines and roles.

Additional sections in the structure of the EHR are tools for practitioners, such as patient screening. Clinical personnel rarely reviewed these struc- tures, whereas managers accessed these more frequently, possibly for auditing purposes. This finding was expected, as screening and subsequent actions are ongoing and ever-changing. The option "Do not know what this is" was included in the survey to assess use of components in the EHR. Most prescrib- ers were not aware of many of the non- physician sections of the record. This finding may explain the low percentage of access for many documents.

The processes used for documen- tation include the methods for docu- menting and accessing components of the EHR as well as the perceived time spent in reviewing and documenting in the EHR. While reports from studies demonstrate a wide variation in time spent documenting, they do show that 19-27% of time is considered average in the IP setting (Yee et al., 2012; Hendrich, Chow, Skierczynski, & Lu, 2008). The fact that most nurses in IP settings work about 12 hours per day can account for up to 4 hours of documentation per day.

Results from this study demon- strate that nurses perceived they spent about 3.5 hours per day documenting, compared to 2 hours spent by their prescriber colleagues. These perceptions are consistent with literature findings. In this research, 62% of bedside RNs indicated that they document more than 3 hours per day, which is about 25% of the workday. For IP providers.

40% of prescribers indicated that they document more than 3 hours per day, and in the ED, 61% reported spending 2.5 to 3.5 hours per day documenting in the EHR. Although we do not have perceptions or measurements of docu- mentation time prior to implementa- tion of the EHR, Scott et al. (2005) note that clinicians perceive spending 30-75 minutes extra per day in documentation with the EHR versus paper records.

Findings from this study add infor- mation about the time clinicians spend reviewing data already documented in the EHR. These findings are signifi- cant in that about 2 hours are spent by nurses reviewing components in the EHR and 1.5 hours are spent doing so by prescribers. Hripcsak et al. (2011) found that most clinicians actually view EHR data for 7-56 minutes per day. Although the current research looked at perceptions, rather than actual time logged into the EHR, 42% of the IP sample perceived spending less than an hour per day reviewing information, and most prescribers and bedside nurses reported spending 90 minutes or less per day. These findings appear to be similar to findings from previous studies in which actual measurements on time and motion were performed.

The outcome measured in this research involves the useflilness of information contained in the EHR. The components of the record that were used most often for care were diagnostic findings and physiologic measures, such as vital signs. This result was expected, given the frequent nature of their use to assess responses to clinical treatments. Surprisingly, our data demonstrate less frequent use of clinical summary areas

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specifically designed by and for clinical workers to simplify review of clinically relevant indicators. One possible expla- nation is that many clinicians were not familiar with these documents.

Hripcsak et al. (2011) found that progress notes of residents and medical students are read by clinicians. Previous history and physical records are also found to be helpful when patients are readmitted. This research study found that, for inpatient EHRs, Diagnostic Results was the most frequently accessed (89%) area by all providers. Physician Orders was also frequently used, in addition to the History and Physical and Progress Notes areas.

According to Creen and Thomas (2008), physicians look to nursing doc- umentation for details about changes in patients' status. Nurses also use informa- tion in summary reports to synthesize patient data between shifts (Staggers, Clark, Blaz, & Kapsandoy, 2011). One of the limitations in electronic documenta- tion is the lack of narrative description about significant events, thus hinder- ing a complete understanding of the patient's "story." In this research, prac- titioners such as prescribers and nurses most commonly used the EHR informa- tion to make clinical decisions for the patient and to gain an understanding of the overall condition of the patient. These practitioners most often look to Vital Signs, Weight/Height/BMI, and Diagnostic Tests for this information. The SPO "loop" is closed through the use of the clinical information con- tained in the EHR to guide patient care decision making and communication.

An important finding from this study was knowledge about which

elements in the EHR are viewed by various clinicians in acute care and how that information is used to guide clinical care. To meet the needs of clinical caregivers, it is key to determine which EHR components are impor- tant to those clinicians and ensure ease of access in user-friendly formats. Our finding on how little prescrib- ers reviewed nursing and ancillary documentation supports results from previous studies. Many hours are spent documenting information that no one uses, potentially reducing time for patient care. The finding that few clinical practitioners review the plan of care may partially explain the common problems of communication and frag- mentation in acute healthcare.

Another important finding in the study was the limited awareness and use of EHR components available for clini- cians. The lack of clinical summaries use may be explained by a lack of awareness or limited useñilness of the tools to guide clinical care. It is essential to engage clinical practitioners with the designers of these documents to meet clinicians' needs as consumers. Creating views of data that are concise, relevant, and mean- ingftil for clinicians may augment their ability to make clinical decisions.

Findings from the sample of practi- tioners in the ED indicate that they use information needed in real time to man- age single episodes of care. Much infor- mation in the ED is passed on in verbal conversations and reviews of previous care. Having access to clinical resumes helps caregivers develop a story about patients who enter the hospital and may explain the frequent use of these résu- més in the ED setting.

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Implications for Managers In Healthcare As regulatory requirements continually evolve, hospitals are under pressure to collect more data that are not pertinent to direct patient care, such as present- on-admission indicators and Core Measures data sets. Clinicians may not be aware of why they are asked to docu- ment this additional information, but they do recognize the burden of time required to do so. Facilities should be cognizant of this perception and avoid redundancy in documentation require- ments. Other implications for optimized use of the EHR include streamlining documentation for concise entry of information and facilitating efficient health information exchange during care transitions.

Clinicians at all levels rely on vital information to make clinical decisions. Automatically populating informa- tion into numerous forms may reduce workload, but it requires information to reside in multiple places in the EHR. Thus, important information may go unread when it resides on flow sheets or forms unfamiliar to the users. Although clinicians go through a mandatory orientation upon hire, they may rely significantly on coworkers to help them use the EHR once they start working. If the more experienced coworkers are not familiar with forms or have developed work-arounds, new hires may follow in those footsteps.

We recommend that leaders and EHR designers be mindful of adding fields for documentation and to include end users in discussions about changes that will involve them. Opportunities for shared documentation between

disciplines may further reduce redun- dant documentation. Providing front- line caregivers with information about availability of clinical summary views and soliciting input on information for inclusion may expedite widespread use. Finally, some areas of the EHR are made up of multiple checkboxes and lists, which may not tell the story of signifi- cant events. Incorporating options for narrative descriptions in a format con- ducive to reading may augment clinician communication and understanding for patient care.

Study Limitations The study had several limitations. It was conducted in a single hospital system and had a low response rate and small sample size; thus, our results are not generalizable across all practice settings. Additionally, we only included team members from the IP and ED settings, and our findings may not be appli- cable to other patient care areas. While we did assess a variety of settings and included subjects from many clinical disciplines, there may have been varia- tion in documentation review practices beyond the study findings. The sample size of provider types was too small to conduct an analysis of difference between particular specialty practices to answer the research questions. Selection bias in the study was possible toward subjects who are comfortable complet- ing online surveys, as they may have been more willing to participate and experience more comfort using an EHR than nonparticipants. Another limita- tion was recall bias and using measures of self-report rather than actual mea- sures of access.

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Future Research Implications for future research may include studies to further understand patterns of information use from the EHR and the effects of using selected components on patient care decisions and patient outcomes. A study using direct observation of clinicians' use of EHR information may yield further understanding of how and why they use it. Studies using methodologies to cap- ture actual access to and timing of EHR components may serve as better mea- sures of EHR use. Finally, further study into the effects of streamlining EHR components with clinician use would add insight into strategies to improve end users' experience with the system.

C O N C L U S I O N Critically evaluating an organization's EHR processes and redesigning its struc- ture to streamline documentation are important steps toward saving time and maximizing efficient use of the system. Findings ftom this study demonstrate that clinical care workers from a vari- ety of disciplines spend a significant amount of time reviewing information ftom the EHR; however, only a few areas are ftequently reviewed. Many areas of the EHR are rarely accessed for review by numerous study participants. It is possible that clinicians operate through real-time use of information, where his- torical documentation may seem irrele- vant. The sections in the EHR ftequently viewed may indicate the data deemed important by clinicians for patient care.

Final Note on the Study Subsequent to this study's completion, the organization's informatics depart- ment used these findings in part to

drive changes through forming a rede- sign team to streamline the EHR and address complexities and redundancies in documentation. Changes in nursing documentation reduced the number of fiow sheets required and included a new "condition narrative" field to allow a more complete telling of the patient's story. In addition, clinical summaries were created to contain meaningful data.

The redesign team also met with the regulatory personnel to ascertain the necessity of discrete elements of documentation to meet government and accreditation requirements. Those com- ponents without clear rationale for use were eliminated. Recently, these changes were implemented and have resulted in positive outcomes, consolidated flow sheets, and approximately half the num- ber of computer clicks needed compared to before the redesign, with positive feedback about the improved ease of use of the EHR.

The heightened level of awareness about what clinicians are asked to docu- ment and increased scrutiny of addi- tions to documentation have proved beneficial, and areas within the EHR identified to have low usage are now assessed for usefulness and considered for elimination.

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Bosman, R., Rood, E., Oudemans-van Straaten, H., Van der Spoel, J., Wester, J., & Zandstra, D. (2003). Intensive care information

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