All ETDs from UAB

Advisory Committee Chair

Jacqueline A Moss

Advisory Committee Members

Eta Berner

Andres Azuero

Patricia Patrician

Gregory Alexander

Document Type

Dissertation

Date of Award

2016

Degree Name by School

Doctor of Philosophy (PhD) School of Nursing

Abstract

The purpose of this study was to evaluate the relationships between method of data entry into electronic health records and anesthesia provider workload on: (a) documentation efficiency, (b) intraoperative anesthesia documentation accuracy, and (c) user satisfaction. The study was separated into three papers. The first paper is an integrative literature review on how accuracy was defined in anesthesia information management systems. The second paper was a state-of-the-science literature review that presents evidence-based guidelines for interface design for data entry into electronic health records. The third paper was an empirical study to detect relationships among all of the concepts of interest previously mentioned. Some of the important findings from the literature reviews include identification of all of the attributes for the concept of documentation quality and how the type of data (unstructured, structured, and semi-structured) to be documented can influence documentation quality. Documentation quality (aka, accuracy) can be defined using the terms correctness, completeness, comprehensiveness, precision, legibility/readability, quantity of data, redundancy of data, and legitimacy. Nursing documentation quality is most often defined using the attributes correctness, completeness, and comprehensiveness. Unstructured data is narrative text that can improve correctness while impairing completeness. Structured data is well suited for improving completeness of data. Semi-structured data can help to reconcile the tension between unstructured data impairing completeness and structured data impairing correctness. This study demonstrated how the specific method of data-entry can impact documentation quality, documentation efficiency, and user-satisfaction. Auto-filling with pre-defined blocks of text had the poorest documentation quality, required the most physical interactions per hour, and had the same user-satisfaction as computer assisted data-entry. Paper-based documentation had the highest documentation quality for gas flow rates and neuromuscular function testing, required the most time to complete, and scored the lowest in user-satisfaction. Computer assisted data-entry scored the highest in overall documentation quality and required the least amount of interactions per hour. Computer assisted data-entry outperformed the other two data-entry methods and should be studied further for maximizing the usability of electronic documentation systems in anesthesia.

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Nursing Commons

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