Quantifying Electronic Medical Record Usability to Improve Clinical Workflow

Electronic health records (EHRs) can interfere with existing clinical workflow, impede physician-patient communication, and increase providers' cognitive load. The potential negative impacts of EHR use are often linked to an incomplete understanding of clinical workflows and actual real-world EHR use patterns. The Institute of Medicine has called for improving EHR usability; however, quantitative evidence for integrating multi-modal activities in clinical settings is insufficient.

This prospective study increased the understanding of how clinical work is actually done in outpatient clinics that use EHRs. The study was conducted at primary and specialty care outpatient clinics at the Veterans Administration. Indicators assessed were EHR utilization, workflow, physician-patient communication, cognitive load, and user satisfaction.

The specific aims of this project were as follows:

• To understand and quantify EHR workflow. 
• To objectively measure clinical workflow activity and verbal and nonverbal patient-provider communication patterns. 
• To solicit physicians' workload and satisfaction for each visit via surveys and interviews. 
• To understand associations between the first three aims and the factors that may explain observed correlations. 

Data analysis found that factors such as visit complexity, patient care needs, and the EHR influence clinical work and variations in physicians' work practices and perceived workload; however, the role of the EHR in contributing to physician dissatisfaction may be less significant than hypothesized. Physicians reported frustration with their EHRs while multimodal data entry, such as voice and natural language commands, reduced the burdensome use of mouse- and keyboard-driven user interfaces. No significant difference in nonverbal communication was detected. Opportunities to eliminate redundant workflows and documentation practices were identified. At the conclusion of the project, the team recommended a socio-technical approach to evaluate how clinicians integrate technologies into daily workflows.