Appl Clin Inform 2019; 10(01): 129-139
DOI: 10.1055/s-0039-1678551
Research Article
Georg Thieme Verlag KG Stuttgart · New York

Electronic Health Record Adoption and Nurse Reports of Usability and Quality of Care: The Role of Work Environment

Ann Kutney-Lee
1   Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
2   Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States
Douglas M. Sloane
1   Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
Kathryn H. Bowles
3   Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
Lawton R. Burns
4   The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, United States
Linda H. Aiken
1   Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
› Author Affiliations
Funding This project was supported by grant number R21HS023805 (PI: Kutney-Lee) from the Agency for Healthcare Research and Quality, and grant number R01NR014855 (PI: Aiken) from the National Institute of Nursing Research, National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the National Institutes of Health.
Further Information

Publication History

06 November 2018

31 December 2018

Publication Date:
20 February 2019 (online)


Background Despite evidence suggesting higher quality and safer care in hospitals with comprehensive electronic health record (EHR) systems, factors related to advanced system usability remain largely unknown, particularly among nurses. Little empirical research has examined sociotechnical factors, such as the work environment, that may shape the relationship between advanced EHR adoption and quality of care.

Objective The objective of this study was to examine the independent and joint effects of comprehensive EHR adoption and the hospital work environment on nurse reports of EHR usability and nurse-reported quality of care and safety.

Methods This study was a secondary analysis of nurse and hospital survey data. Unadjusted and adjusted logistic regression models were used to assess the relationship between EHR adoption level, work environment, and a set of EHR usability and quality/safety outcomes. The sample included 12,377 nurses working in 353 hospitals.

Results In fully adjusted models, comprehensive EHR adoption was associated with lower odds of nurses reporting poor usability outcomes, such as dissatisfaction with the system (odds ratio [OR]: 0.75; 95% confidence interval [CI]: 0.61–0.92). The work environment was associated with all usability outcomes with nurses in better environments being less likely to report negatively. Comprehensive EHRs (OR: 0.83; 95% CI: 0.71–0.96) and better work environments (OR: 0.47; 95% CI: 0.42–0.52) were associated with lower odds of nurses reporting fair/poor quality of care, while poor patient safety grade was associated with the work environment (OR: 0.50; 95% CI: 0.46–0.54), but not EHR adoption level.

Conclusion Our findings suggest that adoption of a comprehensive EHR is associated with more positive usability ratings and higher quality of care. We also found that—independent of EHR adoption level—the hospital work environment plays a significant role in how nurses evaluate EHR usability and whether EHRs have their intended effects on improving quality and safety of care.

Protection of Human and Animal Subjects

This study was reviewed, and received exempt status, by the University of Pennsylvania Institutional Review Board.

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