by Emily I Wallace, RN, MN, CPMHN(C)
Peterborough Regional Health Centre

Citation: Wallace, E. I. (2023). Repetitive Strain Injury and Electronic Medical records: A brief literature review. Canadian Journal of Nursing Informatics, 18(1).  https://cjni.net/journal/?p=10870

Abstract

This brief literature review was inspired by a practical question that arose one year after a regional medical centre adopted a new comprehensive electronic health record (EMR). While the adoption of these systems undoubtedly offers significant improvements to care quality and patient safety, an issue was identified that staff members at this facility were not prepared for – a rapid increase in the development of repetitive strain injury (RSI), particularly in the wrist. A brief literature review of select healthcare databases was conducted to identify the state of the literature on this topic, revealing a gap in the current body of knowledge. While there are several studies available on this topic, the majority are over ten years old. Further research is needed into the current prevalence of EMR-related RSI, appropriate interventions to minimize this risk, and the impact of this risk on modern healthcare workers (HCW).

Keywords: Ergonomics, electronic medical record (EMR), healthcare, repetitive strain injury (RSI), work-related musculoskeletal disorder (WRMSD)

Background

A few months ago, a large cluster of regional hospitals celebrated the first anniversary of the launch of our shared, comprehensive Electronic Medical Record (EMR). Only a few days after the anniversary, I was approached in my classroom by one of the kinesiologists from my facility’s occupational Health, Safety and Wellness department, inquiring if I am involved with EMR training. This is not an unusual question – as the clinical nurse educator for Clinical Information Systems (CIS), and the person who plans the training sessions for all new hires and transfers within the facility, I am approached daily with questions about CIS. The question that followed, however, was not something I had fielded previous questions about. Since going live with the new system, our hospital has been seeing higher numbers of staff reporting repetitive strain injuries (RSI), particularly in their wrists – something that they attributed to the increased amount of “clicking” in their daily routine. And it was not a small issue – dozens of staff over the past few months, with three nurses that same day, prompting our discussion. I provided her with a list of keyboard shortcuts, to lessen the “click-burden” for staff while documenting, and she recommended to the staff that they try using the mouse with their non-dominant hand for an hour every day, to balance out the strain. However, it seemed like there was a need for a larger discussion and a more comprehensive solution. For a risk that was not even on the organization’s risk register at the time of go-live, it was having a significant impact on staff. EMRs are touted to improve documentation efficiency (Shenk et al., 2018) and improve the safety of our patients (Rantz et al., 2018), but these improvements should not be at the expense of the health and safety of the health care workers (HCW). To develop prevention and management strategies, we first need a strong understanding of the scope of the issue. While there have been literature reviews on this topic in the past, many are quite outdated. As such, this paper provides a brief review of the current state of the literature exploring the association between the use of EMRs and repetitive strain injuries, intending to inform prevention and intervention strategies for our facility.

Methods

I conducted a search of two healthcare-specific databases, CINAHL and MEDLINE. Keywords searched included electronic medical record OR computer information system OR electronic health record, OR EMR OR EHR AND repetitive stress injury OR work-related musculoskeletal disorder OR RSI, OR WRMSD. I intended to limit the search to English-language, peer-reviewed articles published within the past 10 years to maintain relevance, due to the rapidly changing landscape of healthcare technology. However, the initial search did not yield any results, so the time restriction was removed. Inclusion criteria included articles discussing RSI or WRMSD in health care workers, with a focus on electronic documentation systems as a contributing or compounding factor. Due to the small number of articles, results were screened manually for inclusion in the review. Despite broadening the scope of the initial literature search, the results were still limited, with five articles selected for inclusion in the final review (Table 1). A secondary search of the above databases using the terms ergonomics OR office ergonomics AND hospital* AND healthcare was conducted, to identify articles discussing the use of office ergonomics in the clinical setting. Inclusion criteria for this portion of the search were English language articles with full text available focused on the use of office ergonomics in the healthcare environment. As the primary aim of this review is to examine literature discussing RSI and WRMSD amongst clinical staff, studies that only discuss hospital administrative workers were excluded. One peer-reviewed article and two periodicals were identified from this portion of the review. However, one of the periodicals summarized a study that was already selected for inclusion, so was excluded from the final review to avoid duplication of results. The reference lists from selected papers were also reviewed to identify additional relevant papers on this topic; one additional study was identified.

Table 1: Final Search Results

Findings

Of the eight articles selected for inclusion in the literature review, three discussed physicians, with two discussing radiologists in particular; three focused on nursing; and two papers were not discipline-specific but discussed the risks of computer use in healthcare in general. Five papers were published in the United States, one in Canada, one in Korea, and one was published in Iran. There was a surprising lack of recent literature on this topic; the most recent paper was published in 2017.

While screening initial search results for eligibility, it became clear that while a significant number of studies examine the prevalence of RSI and WRMSDs in healthcare workers, there is a dearth of studies specifically examining the link between these injuries and increasing EMR use. The majority of studies discussing RSI and WRMSDs in healthcare were focused on those related to transporting, lifting, turning, and repositioning patients, and interventions for their prevention, identification, and treatment. One study that sought to identify health and safety risks faced by front-line nurses did briefly discuss risks posed by EMRs, however, the risk identified was eye strain related to prolonged computer use (Philips & Miltner, 2015). The risk of RSI or WRMSD associated with EMR use was not included in this study.

Five of the studies directly discussed RSI specifically related to electronic documentation systems. Morrison and Lindberg (2008) explored health and safety risks associated with the digitization of healthcare, and musculoskeletal injury was one topic of discussion, elaborating on the interplay of biopsychosocial factors that can increase the risk of RSI, regardless of EMR use. Two studies focused on the risks associated with radiologists and the use of Picture Archiving and Communications Systems (PACS) with no discussion of the risks faced by other healthcare professionals (Sze, et al., 2017; Harisinghani, et al., 2004). These studies both addressed the need for intentional ergonomic design considerations in modern radiology suites and workrooms.

The remaining studies discussed the risk of ergonomic injuries associated with the rapid implementation of EMRs without adequate risk assessment and intervention planning (Hedge & James, 2012; McHugh & Schaller, 1997). Both studies cited the rapid influx of RSI in the 1980s and 1990s due to the rapid digitization of the business sector, highlighting that a similar risk is present in the current healthcare system. Hedge & James (2012) conducted a poll of 197 physicians. This study determined that the majority complain of some form of WRMSD, with this being more common in female physicians than their male counterparts. Paradoxically, while male physicians were more likely to report familiarity with the customization feature of their workstations, female physicians were more likely to report utilizing these features (Hedge & James, 2012). Unsurprisingly, staff who spent higher lengths of time at their computerized workstations reported higher levels of injury (Hedge & James, 2012). McHugh & Schaller (1997) identified potential injury risks and provided ergonomic workstation design suggestions; however, as this periodical was published 26 years ago before the widespread implementation of comprehensive EMRs, many of the risks and workstation designs were speculative and did not directly relate to the current state of the computer equipment used in hospitals. However, some principles discussed were still relevant: adjustable monitor and keyboard height, and training HCWs to protect themselves from injury using safe work practices (McHugh & Schaller, 1997). Neilsen & Trinkhof (2003) also proposed recommendations about nursing workstation design noting that while there is little research around the specifics of nursing workstation design for injury reduction, there is evidence that ergonomics programs are associated with lower levels of injury.

Discussion

Office ergonomics is a well-established field, having experienced significant growth in the 1980s and 1990’s when much of the workforce experienced rapid digitization – leading to a rapid influx of RSI (Hedge & James, 2012). Sufficient risk assessment and planning are required before and during EMR implementations to prevent a similar influx of injuries among clinicians. Hedge & James (2012) argued that during many implementations the system (hardware and software requirements) are the focus, and the ergonomic and biomechanical factors are often less considered in the planning phase. This may result in equipment selection and workstation design that does not adequately address injury risk. For example, many EMR systems support the use of portable electronic devices such as mobile phones and tablets. While the use of these devices may reduce the risk of wrist injury due to clicking, they carry their own risks, such as the development of neck injury (Hedge & James, 2012). As such, it is pertinent that workflow and worker assessments are conducted before the selection and purchase of equipment (Nielsen & Trinkhoff, 2003).

In addition to considering the risk of RSI and WRMSDs during the planning phase, ongoing support and resources are necessary for staff who experience these conditions. Occupational health, safety, and wellness (OHSW) programs are a common employee support service in modern hospitals with documented success at reducing employee injury and lost time (Nielsen & Trinkhoff, 2003). However, the services and programs that they offer may not address the specific risks associated with EMR use. When considering office ergonomics programs, many of the solutions and resources offered primarily focus on office staff and standalone/single-worker workstations; the programs that do focus on clinical staff are often primarily related to body mechanics and safe patient transfers. As nurses are one of the professions at the highest risk of developing WRMSDs and much of the evidence points to turning, repositioning, and lifting patients as a causative factor (Morrison and Lindberg, 2012), there is a good reason that safe patient handling is often a focus of OHSW programming. However, the rapid digitization of the healthcare space may necessitate additional programming to address the associated risks.

These risks are particularly pertinent as more facilities implement comprehensive EMRs – electronic medical records that incorporate all routine documentation required by clinicians in each facility (Rantz et al., 2014), as opposed to electronic medical databases that require concurrent management of a paper medical record. While having all documentation completed in a single system improves efficiency, communication, and continuity of care, they also result in a larger amount of time spent on the computer, causing more repetitive motion and a higher risk of RSI. While some interventions from the office ergonomics field are potentially relevant for reducing the risk of EMR – associated RSI and WRMSD in clinical staff (ensuring proper monitor height and keeping important objects within reach) (Nielsen & Trinkhoff, 2003), I argue that special considerations need to be made to address the specific needs of clinical staff, particularly those working in inpatient departments.

Facilities that implement comprehensive EMRs in the hospital setting often adopt portable workstations or Workstations on Wheels (WOW) to allow staff to document directly at the patient’s bedside. While useful for promoting timely documentation and patient-centered care, these do pose ergonomic challenges. Unlike traditional office workspaces, WOWs are designed to be portable and adaptable, meaning they are often used in different locations throughout the day, by different staff. Even if staff members are assigned a specific workstation for the duration of their shift, it is likely to be used by a different clinician during the opposing shift. As it is unlikely that two staff require the same ergonomic adaptations, this may result in difficulty maintaining the specific placement of monitor distance, device height, keyboard tray adjustments, etc. required to maintain proper biomechanics for reducing injury. Additionally, due to the portable and collapsible nature of these workstations, many additional ergonomic supplies such as curved keyboards, wrist supports, and specialty mice are often incompatible. Finally, as customization of workstations is only beneficial if staff are aware of how to use these features; ensuring that staff are adequately trained on the ergonomic functions and considerations is crucial (Sze et al., 2017) As such, while workstation customization may be beneficial, additional strategies are needed.

Many complaints relating to repetitive strain from computer documentation stem from mouse use, however, aside from equipment replacement, many traditional ergonomic approaches do not target mouse use (Sze et al., 2017). As such, in addition to workstation adjustments, there are also adaptations that staff can make to their computer use habits. Many EMR systems provide keyboard shortcuts as alternatives to traditional mouse clicking to navigate through the program, however, this is generally a reduction in mouse use, not a replacement. Staff can also alternate which hand they use to click the mouse, so that the click burden on any given hand is lessened, however, if additional strategies are not used to reduce the strain on the wrist, this will likely only prolong the time before an RSI develops, rather than being entirely preventative. Additionally, mousing using the non-dominant hand can be slower, which could sacrifice documentation efficiency for busy clinicians with a focus on patient care. Including a proactive session in clinical orientation on the risks and teaching preventative stretches and exercises, workstation setup and customization, and highlighting keyboarding shortcuts to reduce the click-burden in the EMR training will allow staff to take preventative measures before even beginning to work within these systems, before injury occurs (Neilsen & Trinkhoff, 2003; McHugh & Schaller, 1997).

Conclusion

As technology continues to develop and become increasingly prevalent in society, the same can likely be said for the adoption of novel technologies within the healthcare field. While most healthcare providers agree that the purpose of our work is primarily to protect our patients, workplace health and safety for healthcare workers must also be a priority for healthcare organizations. While limited, the current body of research does support that there is a risk of increased musculoskeletal and repetitive strain injury associated with the use of electronic medical records. Further research is needed to determine the scope of this issue and potential solutions, however, there are harm-reduction strategies that can be taken in the meantime. In addition to equipment and workstation considerations, a human-factors approach to risk reduction can be valuable. Educating and empowering staff to take steps to reduce their risk of developing RSI or WRMSD is a viable approach. However, up-to-date research that considers the current state of technology in the health care system is needed to ensure that recommendations and guidelines are relevant to the present day. In a world where many organizations are facing a health human resources crisis, there is an increasing need to consider the health and safety of healthcare workers – including the risks associated with electronic documentation.

Author Biography

Emily I Wallace, RN, MN

Emily Wallace is a Registered Nurse and Certified Psychiatric/Mental Health Nurse from Ontario, Canada. She currently works as the Clinical Nurse Educator for Clinical Information Systems at Peterborough Regional Health Centre and a contract faculty member at the Trent/Fleming School of Nursing. She received her Master of Nursing from the University of Saskatchewan. Her research interests include clinical informatics, simulation, and virtual reality in nursing education.

References

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