Workarounds used by nurses to overcome design constraints of electronic health records

Adoption of electronic health records (EHRs) has the potential to assist with clinical reasoning and streamline workflow; however, the data entry and review capabilities of most systems are suboptimal which may lead to workarounds. As an instance of a workaround, we examined nurses' use of optional free-text comments in EHR flowsheets to support clinical needs for data interpretation. This mixed-method study included: 1) Content analysis of comments, 2) Interviews with nurses. We performed a sub-analysis of flowsheet data for 201 patients that experienced a cardiac arrest and interviewed 5 acute care nurses. We found that nurses used workarounds in the EHR - despite the extra effort that they required - to convey clinically significant relationships and to communicate concerning events to physicians. EHRs should better support entry of clinical data that "belongs together" and enable messaging capabilities integrated with nurses' flowsheet documentation workflow.