Keywords

1 Introduction

An intensive care unit (ICU) is one of the dynamic and problematic areas in a hospital. In ICUs, many nurses are exposed to a hectic environment where they need to provide timely and proper healthcare services to support urgent therapeutic interventions and monitoring intensive patients. According to a study done by Singer and Little [1], the mortality rate among patients who are not critically sick is more than 25%, while this ratio increases more than 40% in the case of patients who are experiencing a complication. Thus, reducing the probability of clinical risks is vital inside the ICU [2, 3].

Several strategies have been proposed to improve the quality of care and operational efficiency in ICUs [4]. One of these strategies is using healthcare information technology [5] to support clinical activities, improve efficiency, reduce errors, improve the quality of care, and reduce the cost of healthcare [6, 7]. An electronic medical record (EMR) system is a digital information equivalent of paper records, which typically contains general information such as treatment, assessment, orders, and patient medical history [8]. The EMRs enable nurses to access their patient’s data over time, identify patients for preventive visits, monitor patients, improve healthcare quality, reduce medical errors, and predict drug interaction [9, 10]. The adverse consequences of HIT systems are including 1) more or new work for clinicians, 2) changes in clinicians’ workflow, and 3) new types of errors regarding entering assessment and medical results [11].

EMR systems affect ICU nurses’ workflow by increasing the documentation time, while decreasing communication time with patients [12]. ICU nurses have spent up to 60% of their time with computers [13], although getting to know the patient and family is essential for providing a good quality of care [14]. Having proper communication and spending more time with patients can help nurses improve their comprehension and retention of patient conditions [15]. However, EMR systems provide enormous digital information regarding their patient’s treatment and conditions.

This study aims to identify the areas of EMR where improvements can be made by preventing disruptions, incompleteness, and helping nurses to have proper communication with patients and their relatives. Thus, having a good understanding of how ICU nurses perform EMR documentation related to updating assessment results will improve healthcare delivery processes. In this study, a time & motion study was conducted in a medical ICU at the University of Missouri Hospital. After that, by combining the data obtained from manual observation forms and real-time measurement system (RTMS), multiple hierarchical task analysis (HTA) charts were developed to understand ICU nurses’ workflow. According to the previous studies [5, 16, 17], all nurses’ activities related to the EMR documentation will be categorized into four main groups, including 1) update assessment results, 2) review documents, 3) check and update medication requests, 4) check lab specimen.

2 Methodology

In this study, the time & motion study was conducted at the University Hospital, University of Missouri-Columbia. Nine ICU nurses participated in this study, and one to three nurses were observed on each observation day from 7:00 a.m. to 7:30 p.m. for 15 days from 2/17/2020 to 3/11/2020. All participants were registered nurses with a range of 1 to 26 years of ICU work experience. All participating nurses were informed about conducting the time & motion study and all collected information related to the nurses and patients was kept confidential. To minimize the Hawthorne effect, observers maintained a considerable distance from the participants and did not initiate any conversation with them. Besides, to maintain patient privacy, observers were not allowed to enter a patient room. The studied ICU had eighteen single-patient rooms in two pods and a reception desk located in the middle of the unit. Each pod had a nurse station equipped with monitors, computers, telephones, tables, and a medicine cabinet.

All log information related to EMR documentation were recorded in the Real-Time Measurement System (RTMS) database. In this study, the RTMS log data was used to analyze nursing work patterns related to the EMR charting [5]. The University of Missouri IRB approved all procedures done in this study.

Three graduate students collected time and activity data with one undergraduate student and recorded the start and end time of each task done by ICU nurses by using an observation form (see Fig. 1).

Fig. 1.
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The manual observation form

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All nursing activities are categorized into five main groups: verbal report, primary care, peer support, out-of-room activities, and non-nursing activities [18]. RTMS data shows the time and work patterns related to nurses’ EMR documentation in an ICU.

3 Data Analysis

The collected data from the manual observation forms and RTMS system were combined to develop a hierarchical task analysis (HTA) chart to have a detailed view of the nurses’ EMR documentation workflow inside and outside the patient room.

3.1 Hierarchical Task Analysis (HTA) Chart

By combining the data gained from the time & motion study and RTMS system, multiple HTA charts were created to show the process of updating assessment results in EMRs. HTA chart breaks down a nurses’ task into sub-tasks. It provides a model for task execution to accomplish the goals of different tasks. For example, HTA might help us to have a better understanding of the ICU nurse work patterns related to updating the assessment results. Figure 2 shows the HTA chart for updating assessment results both inside and outside the patient room.

Fig. 2.
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The HTA chart for updating assessment results

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To construct the HTA chart, all nursing tasks related to updating the assessment results inside and outside the patient room were categorized into ten different processes. To update assessment results inside or outside the patient room, ICU nurses must complete all or a part of these tasks.

In EMR systems, there are two different assessment pages, Interactive View (IView) and Intake and Output second Generation (IO2G), which are mostly used by bedside caregivers (i.e., a respiratory therapist, dialysis nurses, and registered nurses) to add or sign their assessment results. Interactive View (IView) window is a tab in EMR system that allows nurses to chart and organize patient assessment data in a meaningful manner. On the other hand, Intake and Output window is a tab in the EMR system used to document and share the information related to fluids taken and removed from a patient, like urine. Table 1 shows a brief description of each of the HTA chart tasks.

Table 1. The description of tasks in the HTA chart
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4 Results

In this study, a one-way ANOVA was conducted to compare the patterns of EMRs for updating assessment results inside and outside the patient room in terms of average process time. Tables 2 and 3 show the results of ANOVA on the average process time of updating assessment results in EMRs. There are significant differences in average process time inside and outside the patient’s room for sequences 4 (P = 0.005), 1–6 (P = 0.002), 4-1-7 (P = 0.005), and 8-1-7 (P = 0.020). In all these sequences, ICU nurses spent longer process time updating the assessment results in the EMR system outside the patient room.

Table 2. ANOVA results for the average process time of updating assessment results
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Table 3. ANOVA results for the average process time of HTA chart tasks
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5 Discussion

The primary objective of this study is to analyze the documentation patterns of EMRs for updating assessment results in a medical ICU and how these patterns can be different inside and outside the patient room in terms of average process time. Table 2 shows that ICU nurses prefer to spend more time on updating assessment results outside the patient room. Table 3 shows that ICU nurses spend more time on the PDoc Navigation band (task 4) when they use the EMR system outside the patient room. The navigation bar in this task is a ribbon located on the left side of the EMR window. It helps nurses and physicians to access other EMR windows, such as Intake and Output, IView, clinical notes, medication profile, etc. (see Fig. 3(a)). By clicking on these icons provided in this ribbon, ICU nurses will open other windows and navigate the system. This result indicates that ICU nurses might prefer to process more information while working outside the patient room. They accessed more pages, including patient’s documentation, allergies, medication history, etc.

Fig. 3.
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Screenshots of the EMR system

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For Task 7, it is performed to check the accuracy of all inputted data [5]. After adding the results to the IView assessment page, ICU nurses must click on the checkmark button on the toolbar above the navigator band to confirm and sign the assessment results (see Fig. 3(b)). Table 3 shows a significant difference in average process time for sequences 4-1-7 and 8-1-7 compared to sequences 4-1-6 and 4-1-10. It means that nurses prefer to check and measure the vital signs and do the focused assessments and enter the assessment result when they work inside the room. On the other hand, they prefer to check the accuracy and consistency of the assessment results when they work outside the room because they spent a significantly longer time to check the accuracy of all inputted data.

In a patient room, performing focused assessment and adding those results in the EMR system are the top priority tasks for ICU nurses. The key difference between sequence 1–6 and sequence 4-1-6 is whether to use the navigation bar or not. Table 3 also shows a significant difference in the process time for sequence 1–6 between inside and outside the patient room compared to sequence 4-1-6. Furthermore, the standard deviation of sequence 1–6 is increased from 2.96 to 5.36 when the location is changed from inside to outside the room. One possible explanation of this phenomenon could be the design issue related to the PDoc Navigation Band inside the patient room. According to the results, we found a large deviation of using the navigation bar for ICU nurses when adding results in the IView section inside the patient room.

Overall, the findings of the current study revealed that the location of EMR charting has a significant impact on the average process time while updating the assessment results in EMRs. We also identified one usability issue of PDoc Navigation Band ribbon in the EMR system related to adding results in the IView section.

6 Limitation and Future Research

Despite our findings, there are several limitations in this study. First, we only used data from day-shift nurses; so, it would be beneficial to include night-shift nurses and compare the current findings. Second, nurses’ interruption was not considered in our data collection. Although ICU nurses experience multiple interruptions while working during a shift, we did not consider the source of disruption in our data collection. Third, we only collected data from nine ICU nurses. Hence, it would be recommended to have more participants in future studies.