Improving Effectiveness and Satisfaction of an Electronic Charting System in Taiwan

Measuring Documentation Burden in Healthcare

BACKGROUND

The enactment of the Health Information Technology for Economic and Clinical Health Act and the wide adoption of electronic health record (EHR) systems have ushered in increasing documentation burden, frequently cited as a key factor affecting the work experience of healthcare professionals and a contributor to burnout. This systematic review aims to identify and characterize measures of documentation burden.

METHODS

We integrated discussions with Key Informants and a comprehensive search of the literature, including MEDLINE, Embase, Scopus, and gray literature published between 2010 and 2023. Data were narratively and thematically synthesized.

RESULTS

We identified 135 articles about measuring documentation burden. We classified measures into 11 categories: overall time spent in EHR, activities related to clinical documentation, inbox management, time spent in clinical review, time spent in orders, work outside work/after hours, administrative tasks (billing and insurance related), fragmentation of workflow, measures of efficiency, EHR activity rate, and usability. The most common source of data for most measures was EHR usage logs. Direct tracking such as through time-motion analysis was fairly uncommon. Measures were developed and applied across various settings and populations, with physicians and nurses in the USA being the most frequently represented healthcare professionals. Evidence of validity of these measures was limited and incomplete. Data on the appropriateness of measures in terms of scalability, feasibility, or equity across various contexts were limited. The physician perspective was the most robustly captured and prominently focused on increased stress and burnout.

DISCUSSION

Numerous measures for documentation burden are available and have been tested in a variety of settings and contexts. However, most are one-dimensional, do not capture various domains of this construct, and lack robust validity evidence. This report serves as a call to action highlighting an urgent need for measure development that represents diverse clinical contexts and support future interventions.

The impact of evidence-based nursing leadership in healthcare settings: a mixed methods systematic review

BACKGROUND

The central component in impactful healthcare decisions is evidence. Understanding how nurse leaders use evidence in their own managerial decision making is still limited. This mixed methods systematic review aimed to examine how evidence is used to solve leadership problems and to describe the measured and perceived effects of evidence-based leadership on nurse leaders and their performance, organizational, and clinical outcomes.

METHODS

We included articles using any type of research design. We referred nurses, nurse managers or other nursing staff working in a healthcare context when they attempt to influence the behavior of individuals or a group in an organization using an evidence-based approach. Seven databases were searched until 11 November 2021. JBI Critical Appraisal Checklist for Quasi-experimental studies, JBI Critical Appraisal Checklist for Case Series, Mixed Methods Appraisal Tool were used to evaluate the Risk of bias in quasi-experimental studies, case series, mixed methods studies, respectively. The JBI approach to mixed methods systematic reviews was followed, and a parallel-results convergent approach to synthesis and integration was adopted.

RESULTS

Thirty-one publications were eligible for the analysis: case series (n = 27), mixed methods studies (n = 3) and quasi-experimental studies (n = 1). All studies were included regardless of methodological quality. Leadership problems were related to the implementation of knowledge into practice, the quality of nursing care and the resource availability. Organizational data was used in 27 studies to understand leadership problems, scientific evidence from literature was sought in 26 studies, and stakeholders' views were explored in 24 studies. Perceived and measured effects of evidence-based leadership focused on nurses' performance, organizational outcomes, and clinical outcomes. Economic data were not available.

CONCLUSIONS

This is the first systematic review to examine how evidence is used to solve leadership problems and to describe its measured and perceived effects from different sites. Although a variety of perceptions and effects were identified on nurses' performance as well as on organizational and clinical outcomes, available knowledge concerning evidence-based leadership is currently insufficient. Therefore, more high-quality research and clinical trial designs are still needed.

TRAIL REGISTRATION

The study was registered (PROSPERO CRD42021259624).

Interventions to Reduce Electronic Health Record-Related Burnout: A Systematic Review

BACKGROUND

Electronic health records are a significant contributing factor in clinician burnout, which negatively impacts patient care.

OBJECTIVES

To identify and appraise published solutions that aim to reduce EHR-related burnout in clinicians.

METHODS

A literature search strategy was developed following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Six databases were searched for articles published between January 1950 and March 2023. The inclusion criteria were peer-reviewed, full-text, English language articles that described interventions targeting EHR-related burnout in any type of clinician, with reported outcomes related to burnout, wellness, EHR satisfaction, or documentation workload. Studies describing interventions without an explicit focus on reducing burnout or enhancing EHR-related satisfaction were excluded.

RESULTS

We identified 44 articles describing interventions to reduce EHR-related burnout. These interventions included the use of scribes, EHR training, and EHR modifications. These interventions were generally well received by the clinicians and patients, with subjective improvements in documentation time and EHR satisfaction, although objective data were limited.

CONCLUSION

The findings of this review underscore the potential benefits of interventions to reduce EHR-related burnout as well as the need for further research with more robust study designs involving randomized trials, control groups, longer study durations, and validated, objective outcome measurements.

Scoping review: Positive and negative impact of technology on clinicians

BACKGROUND

Unnecessary electronic health record (EHRs) documentation burden and usability issues have negatively impacted clinician well-being (e.g., burnout and moral distress).

PURPOSE

This scoping review was conducted by members from three expert panels of the American Academy of Nurses to generate consensus on the evidence of both positive and negative impact of EHRs on clinicians.

METHODS

The scoping review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines.

RESULTS

The scoping review captured 1,886 publications screened against title and abstract 1,431 excluded, examined 448 in a full-text review, excluded 347 with 101 studies informing the final review.

DISCUSSION

Findings suggest few studies that have explored the positive impact of EHRs and more studies that have explored the clinician's satisfaction and work burden. Significant gaps were identified in associating distress to use of EHRs and minimal studies on EHRs' impact on nurses.

CONCLUSION

Examined the evidence of HIT's positive and negative impacts on clinician's practice, clinicians work environment, and if psychological impact differed among clinicians.

Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review

BACKGROUND

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OBJECTIVE

Electronic health records (EHRs) are linked with documentation burden resulting in clinician burnout. While clear classifications and validated measures of burnout exist, documentation burden remains ill-defined and inconsistently measured. We aim to conduct a scoping review focused on identifying approaches to documentation burden measurement and their characteristics.

MATERIALS AND METHODS

Based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews (ScR) guidelines, we conducted a scoping review assessing MEDLINE, Embase, Web of Science, and CINAHL from inception to April 2020 for studies investigating documentation burden among physicians and nurses in ambulatory or inpatient settings. Two reviewers evaluated each potentially relevant study for inclusion/exclusion criteria.

RESULTS

Of the 3482 articles retrieved, 35 studies met inclusion criteria. We identified 15 measurement characteristics, including 7 effort constructs: EHR usage and workload, clinical documentation/review, EHR work after hours and remotely, administrative tasks, cognitively cumbersome work, fragmentation of workflow, and patient interaction. We uncovered 4 time constructs: average time, proportion of time, timeliness of completion, activity rate, and 11 units of analysis. Only 45.0% of studies assessed the impact of EHRs on clinicians and/or patients and 40.0% mentioned clinician burnout.

DISCUSSION

Standard and validated measures of documentation burden are lacking. While time and effort were the core concepts measured, there appears to be no consensus on the best approach nor degree of rigor to study documentation burden.

CONCLUSION

Further research is needed to reliably operationalize the concept of documentation burden, explore best practices for measurement, and standardize its use.

The efficiency and effectiveness of surgery information systems in Iran

Background

Despite the prevalent use and advantages of information systems in hospitals, some have failed to meet their predefined objectives. Surgery information system (SIS) is a sub-system of a hospital information system. Its effective and efficient operation could enhance patient care in the busy environment of operating rooms with multiple tasks. The objective of this study was to evaluate the effectiveness and efficiency of SIS in three educational hospitals.

Methods

Data were collected using a questionnaire completed by 82 users of SIS. This questionnaire contains three parts: 1) participants’ demographic information, 2) questions regarding the efficiency of SIS, and 3) questions about its effectiveness. An independent sample t-test was used to compare the efficiency and effectiveness among systems. Chi-squared and Fisher tests were used to determine the relationship between the participants’ demographics and efficiency and effectiveness as well as the relationship between efficiency and effectiveness.

Results

About 23% of the participants rated the system’s efficiency as low, 29% as medium, and 48% as high. Besides, 24% of the participants considered the effectiveness of the system as low, 31% as medium, and 45% as high. There was a significant correlation between the efficiency and effectiveness of SIS (p ≤ 0.0001).

Conclusion

Based on the perspective of most participants (44%)the efficiency and effectiveness of both surgery information systems were acceptable. The results suggest that these systems should be designed in a way that facilitate user’s interaction and reduce the time takes to complete tasks. The results could be useful for developing and designing an efficient and effective system.

Methods used to examine technology in relation to the quality of nursing work in acute care: A systematic integrative review

AIMS AND OBJECTIVES

To systematically locate, assess and synthesise research to describe methods used to examine technology in relation to the quality of nursing work in acute care. Specific objectives were to (a) describe the types of nursing work examined; (b) describe methods used to examine technology in nursing work; (c) identify outcomes used to evaluate technology in relation to the quality of nursing work; and (d) make recommendations for future research.

BACKGROUND

New technologies can offer numerous benefits to nurses; however, it is challenging to evaluate health information technologies in relation to the quality of nurses' complex day-to-day work.

DESIGN

A systematic integrative review using a five-step process.

METHODS

Five databases were searched using search terms "nurs*," "workload," "task," "time." Data screening, extraction and interpretation were conducted independently by at least two authors and agreement verified by discussion. Data extraction followed PRISMA guidelines.

RESULTS

Of the 41 studies included, most (87.8%, n = 36) examined physical dimensions of nursing work; 31.7% (n = 13) organisational dimensions; 17.1% (n = 8) cognitive dimensions; and only 12.2% (n = 5) emotional dimensions. More than half (58.5%, n = 24) examined only one dimension; one captured all four dimensions. Most frequently examined technologies were electronic medical/health records (36.5%) and electronic medication management (19.5%). Direct observation (58.8%, n = 28) and multiple methods (19.5%, n = 8) were the most common methods; nurse tasks, frequency, duration and time distribution were variables most often measured.

CONCLUSIONS

Examinations of technology in nursing work often failed to capture the multiple dimensions of this work nor did they recognise the complexity of day-to-day nursing work in acute care. There is a paucity of literature to inform how and what technology should be measured in relation to the quality of nursing care.

RELEVANCE TO CLINICAL PRACTICE

The outcomes inform useful research methods to comprehensively examine technology to enhance the quality of complex nursing work.

Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review

AIM

To review the evidence on the effects/impact of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings.

BACKGROUND

Electronic documentation has been recommended to improve quality care and patient safety. With the gradual move from paper-based to electronic nursing documentation internationally, there is a need to identify interventions that can effectively improve quality care and patient safety.

EVALUATION

We conducted a systematic review on the effectiveness of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings.

KEY ISSUES

Six articles reporting on six individual studies met all eligibility criteria. They were uncontrolled pre/post intervention studies reporting positive impacts on at least one or more outcomes. Most outcomes related to documentation practice and documentation of content.

CONCLUSION

Some evidence from our review indicates that implementing electronic nursing documentation in acute hospital settings is time saving, reduces rates of documentation errors, falls and infections.

IMPLICATIONS FOR NURSING MANAGEMENT

A planned approach from management over time to allow nurses adapt to new electronic systems of documentation would seem a good investment in terms of efficiency of work time, possibly resulting in more time for clinical care.