Understanding clinician engagement with electronic health records: a mixed-methods study of structured data entry using the Theory of Planned Behaviour

Background

Electronic health records (EHRs) are central to NHS clinical practice, and the value of the data they hold depends on clinicians entering structured data. Structured data entry (SDE) is nonetheless used inconsistently, and most evidence comes from US settings documenting barriers rather than the mechanisms interventions must target. This is, to our knowledge, the first study to apply the Theory of Planned Behaviour (TPB) to SDE, to examine SDE behaviour among UK NHS doctors, and to apply corpus linguistics to clinicians’ free-text accounts of EHR use.

Methods

A two-part mixed-methods study was conducted at a large NHS teaching hospital in central London using the Epic EHR. Study 1 was a cross-sectional survey of non-consultant grade doctors comprising the System Usability Scale (SUS), a purpose-designed TPB questionnaire, and two open-text questions analysed using corpus linguistics. Study 2 was an Interpretative Phenomenological Analysis (IPA) of semi-structured interviews with six resident doctors.

Results

Eighty-three doctors responded; 65 completed the SUS and 49 the TPB questionnaire. Mean SUS score was 62.1 (95% CI 58.3-65.9), below the benchmark of 68 and equivalent to a grade of “D”. Structured features were used markedly less often than narrative notes. TPB constructs explained 56% of the variance in intention (F(3,45) = 18.95, p < .001); attitudes (p = .003) and subjective norms (p = .009) predicted intention independently, whereas perceived behavioural control did not (p = .14). Intention predicted self-reported use of problem lists, event-specific templates and standardised documents, but not narrative notes. Corpus analysis identified time pressure and interface friction as dominant barriers. IPA generated four themes: structured documentation as cognitive relief; as fragile collective infrastructure; as a practice clinicians are expected to perform but not enabled to learn; and as a format that can flatten clinical reasoning.

Conclusions

Engagement with SDE is driven principally by attitudes and social norms rather than by perceived control, and the barriers clinicians describe arise from the intersection of interface design, training, team norms and institutional expectation.

Interventions addressing usability alone are unlikely to succeed: sustained change requires team-level normative reinforcement, specialty-relevant training that explains both how and why, and systems that preserve space for clinical narrative.