JONA
Volume 46, Number 7/8, pp 366-372
Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL OF NURSING ADMINISTRATION
The Impact of an Integrated Electronic
Health Record Adoption on Nursing
Care Quality
AnneMarie Walker-Czyz, EdD, RN
OBJECTIVES: The purpose of this study was to mea-
sure the impact of an integrated electronic health
record (EHR) innovation adoption on the quality
of nursing care delivered, including hospital-acquired
falls, hospital-acquired pressure ulcers, ventilator-
associated pneumonia (VAP), central lineYassociated
bloodstream infections (CLABSIs), catheter-associated
urinary tract infections (CAUTIs), and costs measured
in nursing hours. The impact on quality, cost, and
nurse satisfaction measured in turnover rates before,
during, and after implementation of EHR tools was
also investigated.
BACKGROUND: Little is known about the adop-
tion patterns of computerized documentation by nursing
and the effects on the practice environment.
METHODS: A quantitative, retrospective analysis
using interrupted time series model of a large data set
was conducted in a 431-bed urban hospital, with
10 medical surgical units and 2 critical care units.
The research was constructed using the Diffusion of
Innovations (DOI) theory.
RESULTS: Incorporating electronic, evidenced-based
practice (EBP) tools into bedside nurse’s workflow
promotes decision making at the point of care that
may improve quality with no negative impact on direct
cost. The data revealed that total falls, CAUTI, and
CLABSI rates were positively impacted after the
implementation of an integrated EHR. Hospital-
acquired pressure ulcer and VAP rates were nega-
Author Affiliation: St Joseph’s Hospital Health Center, Syracuse,
New York.
The author declares no conflicts of interest.
Correspondence: Dr Walker-Czyz, St Joseph’s Hospital
Health Center, 301 Prospect Ave, Syracuse, NY 13203
(annemarie.czyz@sjhsyr.org).
DOI: 10.1097/NNA.0000000000000360
366
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
tively impacted at the implementation period followed
by a significant positive rate reduction that surpassed
the preimplementation period. Cost indicators, mea-
sured in hours per patient day and overtime, were
negatively impacted during the implementation pe-
riod followed by a return to baseline. Nurse turnover
had a significant increase from the preimplementation
to postimplementation period and failed to return
to baseline.
CONCLUSIONS: This study confirms that nurses
have the ability to positively impact the quality of pa-
tient care through successful innovation adoption
related to the use of EBP computerized documen-
tation tools at the bedside. This study further clarified
the practice environment of nurses during DOI.
Healthcare systems are faced with unprecedented chal-
lenges to meet the increasing demand for services.1
The challenges are multifaceted and require organi-
zational leaders to discover solutions that promote
both quality and cost-effectiveness.2 The innovation
adoption of computerized technology or electronic
health records (EHRs) at the bedside has the po-
tential to provide effective, patient-centered, quality
nursing care.3
EHR Adoption by Nursing
There has been a rapid increase in the application
and adoption of EHRs across care settings.4 Com-
puterized documentation has the potential to en-
hance the quality and safety of care delivery through
embedding evidence-based practice (EBP) standards
into the nurse’s workflow. The use of EBP standards
of care or bundles of care, structured within the EHR
(integrated EHR), promotes decision making by
providing nurses with a checklist of intended care
delivery, which in turn fosters compliance with practice
JONA  Vol. 46, No. 7/8  July/August 2016
standards.5 Understanding and support for the nurse
practice environment and autonomy for decision
making with computerized documentation is critical
in providing quality care, making this an area worth
investigating.6
Before the implementation of the integrated
EHR, the documentation patterns at the research
site were fragmented with variability throughout
the nursing units, evidence of a hybrid workflow, a
combination of electronic and paper charting, re-
dundancy, and absence of essential information. Before
initiating the EHR, a series of focus groups were
conducted to explore how the EHR tool could promote
nursing practice standards. Nurses recommended con-
ducting a literature review for leading practice stan-
dards regarding hospital-acquired condition (HAC)
prevention, revising policies to reflect EBP standards,
developing checklists for the recommended proce-
dures, building electronic documentation screens with
the checklists embedded, educating nurses about the
new electronic tool, using electronic dashboards to
monitor documentation compliance, and providing
performance data at the unit level. These recommen-
dations were implemented.
Purpose of the Research
The purpose of this research was to measure the impact
of adoption of an integrated EHR on the quality of
nursing care delivered. The research questions asked
were as follows: (1) BWhat are the effects of an
integrated EHR on the quality of nursing care
delivered as measured by hospital-acquired falls,
hospital-acquired pressure ulcer (HAPU) rates,
ventilator-associated pneumonia (VAP), central
lineYassociated bloodstream infections (CLABSIs),
and catheter-associated urinary tract infections
(CAUTIs), cost, and nurse turnover rates?[ and (2)
BWhat is the impact of the integration of EHR tools on
quality, cost, and nurse turnover before, during, and
after implementation?[
Theoretical Framework
The Diffusion of Innovations (DOI) theory supports
this study.7 The science of DOI focuses on 3 major
categories: (1) perception of the innovation, (2) char-
acteristics of people who adopt the innovation or do
not, and (3) contextual factors such as communica-
tion channels, rewards, and organizational leadership
support.8 The adoption of innovations and incorpo-
ration of evidenced-based research into healthcare sys-
tems are challenging yet necessary evolutions. Rogers
DOI model8 provides a process to explore the fac-
tors contributing to how an innovation is rejected or
accepted by a group of individuals. This study explored
JONA  Vol. 46, No. 7/8  July/August 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
outcomes of nurse-sensitive indicators to understand
the effect of an integrated EHR post adoption.
Methods
This was a retrospective study using data from a
431-bed urban hospital, with 10 medical surgical units
and 2 critical care units, located in the northeastern part
of the United States. At the time of the study, the
organization employed 1437 RNs; 38% of the direct
care RNs were bachelors prepared, and 50% were
nationally certified. The study examined the impact
of an integrated EHR adoption on the quality of
nursing care, cost, and nurse turnover. The integrated
EHR included revised EBP electronic documentation
tools and computerized nursing care plans. Quality
outcome variables included (1) hospital-acquired pa-
tient falls, (2) HAPUs, (3) CLABSI, (4) CAUTI, and (5)
VAP. Costs included hours per patient day (HPPD)
and overtime (OT). National Database of Nursing
Quality Indicators (NDNQI) data from 2010 through
2013 were used along with existing data from the or-
ganization’s human resource and performance improve-
ment departments.
An interrupted time series (ITS) model investi-
gated data 1 year preYEHR implementation, at the
point of implementation, and 1 year postYEHR im-
plementation. All data were collected monthly for
46 months; the intervention occurred at approxi-
mately month 22. The following hypotheses were
investigated: (1) the quality of nursing care, defined
as HACs, satisfaction, and costs, will improve after
EHR adoption, and (2) the implementation of an
EHR impacts quality, safety, and nurse satisfaction
during the onset of the innovation adoption period
followed by stabilization (return to baseline) or a
positive result.
Data Analysis
Hospital-level aggregate data were entered into the
R statistical package 0.2, and an ITS regression
procedure was used to measure how the EHR tool
impacted the quality nursing care delivered. The
ITS approach is used to establish relationships as a
basis for prediction sequentially over time.9 Interrupted
time series has been supported in the measurement of
efficiency and quality of patient care, especially in
environments where resources are limited such as the
acute care hospital environment.10
Interrupted time series modeling was used to
examine the association of nursing outcomes over
time with the use of EHR technology. The approach
relied on a segmented regression analysis involving a
pre-post design, where the effect is controlled for a
long time trend.11 A time series method is defined as
367
a sequence of measurements taken at (equally spaced)
ordered points in time. The aim of this ITS research
was to analyze the associations between an outcome
and 1 predictor series or intervention. The time series
was plotted again for every variable using piecewise
(or segmented) regression model whereby the rela-
tionship between an x and y is hypothesized to differ
for different intervals of x. The piecewise model
estimates linear relationships between x and y for
each interval, and the intervals are established by a
knot value that, in this research, is the date of the
intervention. A Durbin-Watson test was used on the
residuals to establish serial dependence or correla-
tion.12 The variables included hospital falls, HAPUs,
CAUTIs, CLABSIs, and VAPs. The cost variables
analyzed were HPPD and OT. Nurse satisfaction was
measured by nurse turnover rates. Time series analysis
was applied to evaluate the longitudinal effects of
the intervention, and a regression model was used to
measure the slope of the graph in the preimplemen-
tation as well as postimplementation period, followed
by a t test to compare the 2 periods. In addition, trend
analysis was used. The 2 tools used were smoothing
and fitting a function. Smoothing is controlled by
2 parameters, ! for the estimate of the level at the
current time point and " for the estimate of the slope.13
Fitting a function was used when there was monoto-
nous time series data that could be adequately ap-
proximated by a linear function. These methods were
appropriate for this research study because the data
in the time series were stationary and there were close
to 50 observations in the data. In addition, values of
the estimated parameters are constant throughout
the time series analysis.
Findings
Quality Nursing Care Outcomes
Falls
The analysis of falls data revealed a significant model
effect, F3,42 = 3.57, P = .02, R2 = 0.15 (Figure 1).
Figure 1. Patient falls.
368
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
The EHR model explained a statistically significant
but modest (15%) portion of the variance in falls.
Preintervention, there is a nonsignificant relation-
ship between months and fall rate (b = 0.48, P > .05).
Postintervention shows a significant decline in fall
rates. For every month, fall rates (fall per 1000 pa-
tient days) decrease one-half a fall per 10-month
period. Thus, for research question 1, the null hypoth-
esis is rejected. Consistent with the research question 1
hypothesis, post-EHR data showed a significant decline
in falls.
CAUTI
The analysis of CAUTI data revealed no model ef-
fect, F2,42 = 12.11, P = 7.58, R2 = 0.43 (Figure 2).
The EHR model explained a significant difference
in CAUTI rate reduction preintervention and postin-
tervention. The data demonstrated that CAUTIs
decreased during the preintervention period and in-
creased somewhat post-EHR, and these coefficients
were significantly different, t42 = j3.71, P < .01.
Postintervention shows a sustained reduction signifi-
cant from the EHR intervention consistent with both
hypotheses.
CLABSI
The analysis of CLABSI data revealed a significant
model effect, F2,42 = 6.52, P < .01, R2 = 0.23 (Figure 3).
The EHR model explained a significant portion of
the variance in CLABSI. The data showed that
CLABSIs decreased during the preintervention period
and increased somewhat post-EHR, followed by
a reduction, and these coefficients were significantly
different, t42 = j2.55, P < .01. Postintervention
shows a continual decline in CLABSI rate after the
increase with the EHR intervention period; for every
month, CLABSI rates (infection per 1000 patient days)
decrease less than half an infection per 10-month
period, consistent with rejecting the null hypothesis
and consistent with hypothesis 1.
HAPUs
The analysis of HAPU data revealed no significant
model effect, F3,41 = 60.99, P > .05, R2 = 0.80
(Figure 4). The EHR model explained no statistically
significant portion of the variance in ulcers preinter-
vention or postintervention. Therefore, hypothesis
1 was not supported. The data showed that ulcers
decreased during the preintervention period and
increased somewhat post-EHR, followed by a reduc-
tion consistent with the preintervention period.
Postintervention shows a continual decline in ulcer
rates after the increase with the EHR intervention
period, which supports hypothesis 2.
JONA  Vol. 46, No. 7/8  July/August 2016
Figure 2. CAUTIs per patient days.
VAP
The analysis of VAP data revealed no model effect,
F2,42 = 16.77, P > .05, R2 = 0.51 (Figure 5). The EHR
model explained no significant portion of the variance
in VAP. Ventilator-associated pneumonias decreased
dramatically (b = j0.24, P = .0007) during the prein-
tervention period and increased somewhat imme-
diately post-EHR. This was followed by a significant
reduction (b = j0.09, P = .001) in the post-EHR
intervention period similar to the pre-EHR. Consis-
tent with hypothesis 2, post-EHR data showed a
slight increase at the time of intervention followed
by a reduction consistent with the preintervention
period.
Cost
Hours per Patient Day
The analysis for HPPD revealed no significant differ-
ence between preintervention and postintervention,
F2,42 = 28.36, P = 3.48, adjusted R2 = 0.65 (Figure 6).
The overall effect of time on HPPD is not significant
(P > .05). The data showed that the EHR interven-
tion had no significant change after the intervention,
consistent with hypothesis 2.
Figure 3. CLABSI per patient day.
JONA  Vol. 46, No. 7/8  July/August 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Figure 4. HAPU incidence per patient day.
OT
The analysis of OT data revealed a significant model
effect, F2,42 =3.07, P = .03, R2 = 0.12 (Figure 7). The
preintervention EHR model explained a significant
decrease and a slight increase at the time of the
intervention and postintervention period followed
by a reduction consistent with the preintervention pe-
riod, which was not significant (P = .15). The null
hypothesis was rejected. The data showed that OT
decreased significantly during the preintervention
period and increased somewhat post-EHR before
returning to baseline, consistent with hypothesis 1.
Nurse Turnover
Nurse turnover data analysis revealed findings that
were inconsistent with both research questions and
hypotheses. The number of nurses who departed
from medical surgical units or intensive care units
during the 46-month study period was averaged by
the total number of nurses divided by 100 to establish
a rate for data analysis. Nurse turnover was collected
separately and analyzed for adult medical surgical
and critical care units. Medical surgical nurse turnover
pre-EHR implementation period was consistent. The
Figure 5. VAP incidence per patient day.
369
Figure 6. HPPD trends.
rate decreased slightly during the initial implementa-
tion period and was followed by a significant increase
in turnover for the remainder of the time periods
studied. Medical surgical nurse turnover rates never
returned to baseline (Figure 8). Critical care nurse
turnover rates remained constant during the imple-
mentation period; graphical analysis revealed a slight
increase over time in the postintervention period, but
it was not significant (Figure 9).
The analysis of nurse turnover data for medical
surgical nursing units revealed no significant model
effect, F2,42 = 2.09, P > .05, R2 = 0.07 (Figure 8),
nor did the model explain the variance in nurse
turnover. The data showed that nurse turnover was
flat during the preintervention period and decreased
somewhat immediately post-EHR followed by a
significant increase (b = 0.08, P = .05). In addition,
these coefficients were significantly different, t42 =
5.008, P < .01. Post-EHR, there was a significant
increase in nurse turnover over time, which did not
support either hypotheses.
The analysis of nurse turnover data for critical
care nursing units revealed no significant model effect,
F2,42 = 0.46, P > .05, R2 = j0.07. Nurse turnover
was flat during the preintervention period and de-
Figure 7. Overtime hours.
370
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Figure 8. Medical surgical nurse turnover.
creased slightly immediately post-EHR, followed by
a slight increase. Neither coefficients were significantly
different with P > .05.
Discussion
This study increases the understanding of the rela-
tionship between EHR adoption and its effect on
quality and cost outcomes. The findings indicate that,
overall, the implementation of an integrated EHR can
positively impact quality outcomes. A 15% reduction
in hospital fall rates could be attributed to the EHR
intervention. Catheter-associated urinary tract infec-
tion and CLABSI rates significantly improved over
time from the preintervention to postintervention period.
Hospital-acquired pressure ulcer and VAP rates in-
creased somewhat during the implementation period
followed by a significantly higher rate of reduction
postimplementation, resulting in nearly the elimina-
tion of the infection. The cost of care measured in
HPPD and OT was not significantly affected. How-
ever, this finding may inform the higher-than-expected
nurse turnover results over time because staffing pat-
terns may not have been supported throughout the
adoption period; increased costs related to nurse
Figure 9. Critical care nurse turnover.
JONA  Vol. 46, No. 7/8  July/August 2016
turnover may have resulted. The impact of EHR
implementation on nurse staffing might vary by the
level of sophistication of the EHR, user, and phases
of adoption.14 Diffusion of Innovations theory pro-
vides insight into the processes for successful adop-
tion of changes in nursing practice. This study’s
research methodology used information from the
past to assist in developing conclusions that can predict
outcomes for the future when DOI occurs. The success
of innovation adoption, such as an integrated EHR, is
dependent upon an organization’s ability to support
DOI. In this study, the quality of care improved or
remained consistent with past hospital performance.
Similarly, Duffy et al15 determined a significant, mar-
ginal improvement regarding nursing quality out-
comes after EHR implementation.
This study confirms that nurses have the ability to
positively impact the quality of patient care through
successful innovation adoption related to computerized
documentation at the bedside. To provide excellent
patient care and maintain control over their work
environment during the implementation of an EHR, a
combination of changes must occur, including devel-
opment of evidenced-based education with standards
of care, monitoring of practice standards, redesign of
nursing units for efficiency,16 and a modification of
certain nursing activities.17
Existing research is lacking regarding the type
of computerized documentation instruments that
would both promote adoption and enhance the quality
of documentation. Future research studies are war-
ranted regarding how nurses use EHR resources for
decision making. Continued research is also necessary
to identify RN turnover risks and mitigation strat-
egies after innovation adoption including implementing
an EHR.
Limitations
Limitations to this study include the use of existing
data because the data have been collected and not
designed by the researcher. However, NDNQI data
are widely used to measure nursing practice and staffing
metrics. In addition, ITS design recommends using
50 data points; this study had 46. Consultation with
References
1. Ankner M, Coughlin C, Holman V. Nurse engagement across
the continuum. Nurse Lead. 2010;8(5):30-32.
2. Hagbaghery MA, Salsali M, Ahmadi F. The factors facilitat-
ing and inhibiting effective clinical decision-making in nursing:
a qualitative study. BMC Nurs. 2004;3(1):2.
3. Carlson E, Catrambone C, Oder K, et al. Point-of-care tech-
nology supports bedside documentation. J Nurs Adm. 2010;
40(9):360-365.
JONA  Vol. 46, No. 7/8  July/August 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
an experienced statistician confirmed that 46 data
points would provide a valid data set for this study.
Last, the quality, cost, and nurse turnover outcomes
cannot be isolated solely to the EHR intervention.
The research site had implemented ongoing strategies
to improve these outcome measures before, during,
and after implementation of an integrated EHR into
bedside nurse workflow.
Implications for Nurse Executives
This study reinforces the power of leadership through
innovation adoption. Successful EHR implementation
requires nurse executives to include bedside nurses in
the decision-making process, have effective commu-
nications with the ability to trial new practices, and
prepare for continuous staffing adjustments.18 Sup-
port includes evaluating staffing through DOI, timely
revisions to the electronic tools based on nurse’s
feedback, and adequate bedside devices. On the
basis of this study, the use of evidenced-based EHR
tools integrated into direct care nursing practice
decreased HACs. Effective nurse-driven staffing
models need to be considered during change adop-
tion and should include the nurse-to-patient ratio,
unit complexity, individualized patient needs, and
the competency of the nurses caring for patients
during the change adoption period, and beyond, to
promote nurse retention.17 A recommendation for
practice would be to increase staffing during the
implementation period and throughout the adop-
tion phases. This tactic may mitigate any increased
risk of HACs during the implementation phase, as
well as reduce nurse turnover. The ITS model helped
to correlate the relationship of research-based innova-
tions with potential users of such innovation in a
knowledge use process.19
The ability to have nurses possess EBP tools at
the point-of-care delivery informs their practice and
allows for improved decision making. This study
supports the emerging relationship between the use
of EHR functionality and the importance for nurses
to lead quality improvement initiatives such as the
use of the electronic information to improve critical
thinking to deliver quality patient care.20
4. Himmelstein DU, Wright A, Woolhandler S. Hospital com-
puting and the costs and quality of care: a national study. Am
J Med. 2009;123:40-46.
5. Cornell P, Riordan M, Herrin-Griffith D. Transforming
nursing workflow, part 2: the impact of technology on nurse
activities. J Nurs Adm. 2010;40:432-439.
6. Mrayyan MT. Nurses’ anatomy: influence nurse managers’
actions. J Adv Nurs. 2004;45(3):326-336.
371
 7. News-on-Mobile Newsland. Diffusion of Innovation theory.
News-on-Mobile.com Web site. Available at http://quipuapps.
com/wp content/uploads/2012/01/diffusion_of_innovation_
theory_.pdf. Accessed January 26, 2013.
8. Berwick DM. Disseminating innovations in health care. JAMA.
2003;289(15):1969-1975.
9. Glass G. Study Guide for Quasi-experimental Research
Methods in Education: Time Series Experiments. Washington,
DC: American Educational Research Association; 1997.
10. Portney L, Watkins M. Foundations of Clinical Research:
Applications to Practice. Upper Saddle River, NJ: Prentice
Hall Health; 2000.
11. Center for Statistical Methodology. Time Series Regression
Analysis. 2014. Available at http://csm.lshtm.ac.uk/themes/
time-series-regression-analysis. Accessed January 26, 2013.
12. Seber GA, Lee AJ. Linear Regression Analysis (936). Hoboken,
NJ: John Wiley & Sons; 2012.
13. Coghlan A. A Little Book of R For Time Series Release 0.2.
Cambridge, England: Wellcome Trust Sanger Institute; 2013.
14. Furukawa MF, Raghu TS, Shao BB. Electronic medical records,
372
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
nurse staffing, and nurse-sensitive patient outcomes: evidence
from the national database of nursing quality indicators. Med
Care Res Rev. 2011;63(3):311-331.
15. Duffy WJ, Kharasch MS, Du H. Point of care documenta-
tion impact on the nurseYpatient interaction. Nurs Adm Q.
2010;34(1):E1-E10.
16. Cornell P, Herrin-Griffith D, Keim C, et al. Transforming
nursing workflow, part 1: the chaotic nature of nurse activities.
J Nurs Adm. 2010;40:366-373.
17. Spence Lasheringer HK, Leiter MP. The impact of nursing
work environments on patient safety outcomes: the mediat-
ing role of burnout/engagement. J Nurs Adm. 2006;36(5):
259-267.
18. Blosky MA, Spegman A. Let’s talk about it: communication
and a healthy work environment. Nurs Manage. 2015;46(6):
32-38.
19. Rogers EM. Diffusion of Innovations. New York, NY: Free
Press; 2003.
20. Beck G, Puthoff D, Gillespie GL. Helping leaders emerge
from the bedside. Nurs Manage. 2015;46(5):34-39.
JONA  Vol. 46, No. 7/8  July/August 2016