The American Medical Informatics Association (AMIA) defines documentation burden as the stress resulting from excessive work required to document in the electronic health record (EHR). The information technology (IT) healthcare systems’ nursing documentation team partnered with documentation improvement committees comprised of front-line nurses and senior nursing leadership to determine perceived barriers to documentation in the EHR.

Purpose: This quality improvement project explored the perception of documentation challenges and burden related to the EHR among inpatient nurses practicing in an academic health system (AHS) and identified improvement strategies.

Methodology: This project used a convergent mixed method approach. Qualitative data was collected during five focus groups, guided by questions related to the EHR. Each session was recorded, transcribed, and anonymized. 20 nurses across the AHS participated. The transcripts were analyzed in aggregate by the project team. Thematic analysis was conducted. Themes and sub-themes were identified. Deidentified quantitative data was collected from the EHR vendor, including active time in the EHR, provided in aggregated monthly intervals. Time in each activity and activity type within the EHR were calculated for clinical nurses. The number of shifts worked in the monthly interval, relevant clinical data such as number medications administered, and notes written also were provided by the vendor. Clinical nurses were defined as nurses having at least one medication administration per shift.

Findings: 20 nurses participated in the focus groups from across the system. 42% were from the adult medical-surgical area. 70% were full-time employees, with 35% having between 3-5 years of experience. While there was representation from the pediatric and adult services, half of the participants were from the adult medical-surgical area. The major themes that emerged from the anonymized focus groups included empowerment, workflow opportunities, nuisances, and communication. The sub-themes identified were uninterrupted documentation time, non-meaningful documentation, consistency, redundancy, education and training opportunities, and flowsheet utilization. Focus group participants perceived their time spent in the EHR at approximately 40%. The vendor system time data showed that the average time spent in the EHR was 19% across the health system. This was less than half of the focus group’s perceived time spent in the system. Overall, participants were favorable regarding the focus group format.

Conclusion: Front-line nursing perspectives in workflow redesign is imperative in identifying interventions to promote adoption and EHR satisfaction. Nurses may not always recognize the need for documentation optimization nor understand the rationale for certain documentation in clinical practice and how it can reduce their perceived burden. We recommend continuing to build partnerships between IT and clinical leadership to inform nurses in a timely fashion of the clinical value of documentation updates occurring in the EHR. Future work will include determining the existence of duplicative documentation, identifying successful communication methods regarding upcoming enhancements, and considering focus group format to explore the EHR documentation needs of various specialties.

Kathleen Zavotsky discloses that she is the editor of a textbook published by Elsevier.

John Will MPA

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