Characteristics and contributors to workarounds in the electronic health record system among inpatient nurses: Secondary analysis of a mixed-methods study.

BACKGROUND: The electronic health record system is known to have usability issues, in part, because of a mismatch between the design of electronic health record workflows and the realities of how workflows occur in clinical practice. In response to reducing this mismatch, healthcare workers, including nurses, have developed and implemented electronic health record workarounds. However, the nature and contributors of these workarounds are loosely understood, particularly among nurses, who make up the most common type of electronic health record user.

OBJECTIVES: 1) To identify and characterize electronic health record workarounds used by inpatient nurses, 2) to determine work system factors contributing to the need for these workarounds, and 3) to understand how different levels of electronic health record usability influence the need for these workarounds.

MATERIALS AND METHODS: This study was a secondary analysis of a larger mixed-methods study on how electronic health record usability influences nursing documentation burden across flowsheets, medication administration records, care plans, notes, and admission-discharge-transfer navigators. The present study used a convergent design to re-examine the interview data and usability survey responses originally collected from 20 inpatient nurses at a teaching hospital. Semi-structured interview transcripts were inductively analyzed to identify unique workarounds and deductively analyzed to examine work system contributors. Documentation features were grouped based on above vs. below average overall usability scores and compared for unique workarounds and contributing factors.

RESULTS: We identified eleven electronic health record workarounds, though some were used for specific documentation features rather than applied universally. All levels of the work system (e.g., electronic health record design, clinical environment) influenced nurses' needs for workarounds. Electronic health record usability levels influenced the specific workarounds used but not the work system contributors.

DISCUSSION: Electronic health record workarounds are context-dependent and future research should contextualize what feature or task the workarounds were used for. Although some workarounds exist because of clinical necessity (e.g., prioritizing decompensating patients over documentation), other workarounds occurred from work system issues (e.g., lack of declarative knowledge on where to document certain information, integration issues between the electronic health record and connected devices) that can be targets for future interventions.

CONCLUSIONS: Nurses' use of electronic health record workarounds is influenced by both electronic health record usability and the broader nursing work system. Future research is needed to quantify their frequency and assess their impact on health outcomes.