INTRODUCTION: Mixed methods are used to holistically understand the "what", "how", and "why" questions within a single study by integrating quantitative and qualitative methods. Although this approach has demonstrated value in other disciplines, their use in applied clinical informatics research remains largely unexplored. This methodological review characterized the types of informatics intervention studies that used mixed methods designs and the specific methods of evaluation and reporting. MATERIALS AND METHODS: On December 13, 2024, we searched Embase, MEDLINE, PubMed, CINAHL and PsycINFO for studies that reportedly used a mixed methods design to study the development or evaluation of clinical informatics interventions. We developed themes in topics studied, designs used, and reporting issues. Quality assessment was conducted using the Mixed Methods Appraisal Tool. RESULTS: We included 54 studies. Despite being described as mixed methods, 14 studies (25.9%) lacked the integration of quantitative and qualitative data. Of the remaining studies, convergent study designs were commonly used. Mixed methods were predominantly used during pre-implementation and post-implementation evaluations. Quality issues included non-representative samples and non-reporting of qualitative approaches and paradigms. DISCUSSION AND CONCLUSIONS: The use of mixed methods to study clinical informatics development and implementation is uncommon. This review confirmed that reporting and design problems found in other disciplines extend to informatics. Calls to action include a need to disseminate mixed methods guidance within the informatics community and offer mixed methods training in graduate programs. We also synthesized an initial reporting checklist from the literature. Our findings offer baseline levels to assess educational efforts.

OBJECTIVES: Examine electronic health record (EHR) use and factors contributing to documentation burden in acute and critical care nurses. MATERIALS AND METHODS: A mixed-methods design was used guided by Unified Theory of Acceptance and Use of Technology. Key EHR components included, Flowsheets, Medication Administration Records (MAR), Care Plan, Notes, and Navigators. We first identified 5 units with the highest documentation burden in 1 university hospital through EHR log file analyses. Four nurses per unit were recruited and engaged in interviews and surveys designed to examine their perceptions of ease of use and usefulness of the 5 EHR components. A combination of inductive/deductive coding was used for qualitative data analysis. RESULTS: Nurses acknowledged the importance of documentation for patient care, yet perceived the required documentation as burdensome with levels varying across the 5 components. Factors contributing to burden included non-EHR issues (patient-to-nurse staffing ratios; patient acuity; suboptimal time management) and EHR usability issues related to design/features. Flowsheets, Care Plan, and Navigators were found to be below acceptable usability and contributed to more burden compared to MAR and Notes. The most troublesome EHR usability issues were data redundancy, poor workflow navigation, and cumbersome data entry based on unit type. DISCUSSION: Overall, we used quantitative and qualitative data to highlight challenges with current nursing documentation features in the EHR that contribute to documentation burden. Differences in perceived usability across the EHR documentation components were driven by multiple factors, such as non-alignment with workflows and amount of duplication of prior data entries. Nurses offered several recommendations for improving the EHR, including minimizing redundant or excessive data entry requirements, providing visual cues (eg, clear error messages, highlighting areas where missing or incorrect information are), and integrating decision support. CONCLUSION: Our study generated evidence for nurse EHR use and specific documentation usability issues contributing to burden. Findings can inform the development of solutions for enhancing multi-component EHR usability that accommodates the unique workflow of nurses. Documentation strategies designed to improve nurse working conditions should include non-EHR factors as they also contribute to documentation burden.

OBJECTIVES: Well-designed electronic health records (EHRs) training programs for clinical practice are known to be valuable. Training programs should be role-specific and there is a need to identify key implementation factors of EHR training programs for nurses. This scoping review (1) characterizes the EHR training programs used and (2) identifies their implementation facilitators and barriers. MATERIALS AND METHODS: We searched MEDLINE, CINAHL, PsycINFO, and Web of Science on September 3, 2023, for peer-reviewed articles that described EHR training program implementation or delivery to nurses in inpatient settings without any date restrictions. We mapped implementation factors to the Consolidated Framework for Implementation Research. Additional themes were inductively identified by reviewing these findings. RESULTS: This review included 30 articles. Healthcare systems' approaches to implementing and delivering EHR training programs were highly varied. For implementation factors, we observed themes in innovation (eg, ability to practice EHR skills after training is over, personalizing training, training pace), inner setting (eg, availability of computers, clear documentation requirements and expectations), individual (eg, computer literacy, learning preferences), and implementation process (eg, trainers and support staff hold nursing backgrounds, establishing process for dissemination of EHR updates). No themes in the outer setting were observed. DISCUSSION: We found that multilevel factors can influence the implementation and delivery of EHR training programs for inpatient nurses. Several areas for future research were identified, such as evaluating nurse preceptorship models and developing training programs for ongoing EHR training (eg, in response to new EHR workflows or features). CONCLUSIONS: This scoping review highlighted numerous factors pertaining to training interventions, healthcare systems, and implementation approaches. Meanwhile, it is unclear how external factors outside of a healthcare system influence EHR training programs. Additional studies are needed that focus on EHR retraining programs, comparing outcomes of different training models, and how to effectively disseminate updates with the EHR to nurses.

OBJECTIVE: This study aimed to understand the association between primary care physician (PCP) proficiency with the electronic health record (EHR) system and time spent interacting with the EHR. MATERIALS AND METHODS: We examined the use of EHR proficiency tools among PCPs at one large academic health system using EHR-derived measures of clinician EHR proficiency and efficiency. Our main predictors were the use of EHR proficiency tools and our outcomes focused on 4 measures assessing time spent in the EHR: (1) total time spent interacting with the EHR, (2) time spent outside scheduled clinical hours, (3) time spent documenting, and (4) time spent on inbox management. We conducted multivariable quantile regression models with fixed effects for physician-level factors and time in order to identify factors that were independently associated with time spent in the EHR. RESULTS: Across 441 primary care physicians, we found mixed associations between certain EHR proficiency behaviors and time spent in the EHR. Across EHR activities studied, QuickActions, SmartPhrases, and documentation length were positively associated with increased time spent in the EHR. Models also showed a greater amount of help from team members in note writing was associated with less time spent in the EHR and documenting. DISCUSSION: Examining the prevalence of EHR proficiency behaviors may suggest targeted areas for initial and ongoing EHR training. Although documentation behaviors are key areas for training, team-based models for documentation and inbox management require further study. CONCLUSIONS: A nuanced association exists between physician EHR proficiency and time spent in the EHR.

OBJECTIVE: Physicians often describe the electronic health record (EHR) as a cumbersome impediment to meaningful work, which has important implications for physician well-being. This systematic review (1) assesses organizational, physician, and information technology factors associated with EHR-related impacts on physician well-being; and (2) highlights potential improvements to EHR form and function, as recommended by frontline physicians. MATERIALS AND METHODS: The MEDLINE, Embase, CINAHL, PsycINFO, ProQuest, and Web of Science databases were searched for literature describing EHR use by physicians and markers of well-being. RESULTS: After reviewing 7388 article, 35 ultimately met the inclusion criteria. Multiple factors across all levels were associated with EHR-related well-being among physicians. Notable predictors amenable to interventions include (1) total EHR time, (2) after-hours EHR time, (3) on-site EHR support, (4) perceived EHR usability, (5) in-basket burden, and (6) documentation burden. Physician recommendations also echoed these themes. CONCLUSIONS: There are multiple complex factors involved in EHR-related well-being among physicians. Our review shows physicians have recommendations that span from federal regulations to organizational policies to EHR modifications. Future research should assess multipronged interventions that address these factors. As primary stakeholders, physicians should be included in the planning and implementation of such modifications to ensure compatibility with physician needs and clinical workflows.

OBJECTIVE: Although nurses comprise the largest group of health professionals and electronic health record (EHR) user base, it is unclear how EHR use has affected nurse well-being. This systematic review assesses the multivariable (ie, organizational, nurse, and health information technology [IT]) factors associated with EHR-related nurse well-being and identifies potential improvements recommended by frontline nurses. MATERIALS AND METHODS: We searched MEDLINE, Embase, CINAHL, PsycINFO, ProQuest, and Web of Science for literature reporting on EHR use, nurses, and well-being. A quality appraisal was conducted using a previously developed tool. RESULTS: Of 4583 articles, 12 met inclusion criteria. Two-thirds of the studies were deemed to have a moderate or low risk of bias. Overall, the studies primarily focused on nurse- and IT-level factors, with 1 study examining organizational characteristics. That study found worse nurse well-being was associated with EHRs compared with paper charts. Studies on nurse-level factors suggest that personal digital literacy is one modifiable factor to improving well-being. Additionally, EHRs with integrated displays were associated with improved well-being. Recommendations for improving EHRs suggested IT-, organization-, and policy-level solutions to address the complex nature of EHR-related nurse well-being. CONCLUSIONS: The overarching finding from this synthesis reveals a critical need for multifaceted interventions that better organize, manage, and display information for clinicians to facilitate decision making. Our study also suggests that nurses have valuable insight into ways to reduce EHR-related burden. Future research is needed to test multicomponent interventions that address these complex factors and use participatory approaches to engage nurses in intervention development.