Participants were five third-year nursing students in a four-year nursing program at a university in Seoul, Korea. These third-year nursing students started their first clinical practicum in March 2014 and had been using a PC-based EMR for their clinical practicum. The recruit flyer explaining this pilot study was posted on a bulletin board. The study was conducted in July and August 2014.

The device was an iPad mini with retina display with a secured wireless network connection that allowed access to the EMR for patient information with protection. Thus, users could not access the EMR through any other wireless network connection. In addition, a passcode was set to protect data in a device. We selected this among iOS-based tablet devices owing to its portability, weight, and resolution, which made it easy to carry and provided good screen quality for diagnostic imaging.

We added several features to the current EMR application to create an AEMR environment. Because the EMR application presented real-time patient information, the AEMR was set to be read-only to prevent accidental altering of patient records by students. To supplement the limitation of this EMR application, we created a series of document forms on an external application, Numbers, which is a spreadsheet application that allows users to enter numbers or texts. The documents built into Numbers include nursing admission notes, vital signs, and intake/output. In addition, several scales were designed to assist students in assessing patient information regarding fatigue, sleep quality, and so on. Those forms were created with a built-in calculation function so that the total score could be automatically added when students entered data. Lastly, those documents and scales were set to be sent to the students' email accounts for further use as a study resource. Figure 1 shows a participant entering vital sign data on the vital sign sheet on the AEMR.

The case scenarios and tasks were created by a research team to evaluate aspects of AEMRs, including their usability and functionality. We selected two patient cases from the EMR and developed 22 tasks for usability and functionality assessment. The cases and tasks were based on a normal clinical day in a hospital. Tasks had varying levels of difficulty from "Log into the AEMR application" to "Interview a patient, fill in the nursing assessment document form (or fatigue scale), and send it to your e-mail" and Table 1 shows the tasks used in this study. For the task of interviewing a patient, one research assistant acted as a patient to answer a participant's inquiry.

Two clinical instructors from the college of nursing reviewed these cases and tasks prior to the pilot test. They recommended adding a task pertinent to nursing diagnosis and nursing record keeping. Finally, 22 tasks were developed, and eight tasks among these were common to both cases, and seven tasks unique to each case, which yielded a total of 15 tasks per case. The two scenarios used in this pilot study are summarized below.

Among students who were recruited for this pilot study, a convenient meeting time was scheduled for each participant with our research team to carry out an individual usability assessment. After a participant gave an informed consent, a 15-minute introductory overview on how to use the application followed. Each participant was given a paper sheet of one case with random choice and a test device, an iPad mini with retina display with a secured wireless network connection. They were then asked to complete the patient case with 15 tasks using the AEMR application on an iPad. Participants were provided as much time as required to complete the tasks.

We used the 'think-aloud' method, which is known as an effective method to assess a users' ability to interact with technology by asking them to express verbally what they are thinking about as they interact with technology [1112]. Student participants were asked to talk aloud while they solved tasks. The comments from participants were recorded and transcribed by our research team to extract the strengths and weaknesses of the AEMR application, which were used to modify and refine the AEMR application.

The duration of each task was checked, and user interactions with the software were recorded using both screen-recording software and a camcorder. After the tasks were completed, we asked the participants to share any problems encountered when they navigated the application to complete the tasks. The required time commitment for each participant was approximately 60 minutes: instructions for the test for 15 minutes, usability assessment for about 20-30 minutes, and interview for 15 minutes.

After completion of the participation, a gift card valued at $20 was provided to each participant. This study was approved by the Institutional Review Board of the Yonsei University College of Nursing in Seoul, South Korea (No. 2014-0026-1).

The mean time required for each student to complete the tasks was 19 minutes 39 seconds, with all times ranging from 11 minutes 9 seconds to 23 minutes 55 seconds. The most difficult tasks were "Find the result of the nutritional assessment and current diet" and "Assess the standard patients and fill out the admission nursing documentation in the linked document form." The easiest tasks were "Log out" and "Select the target patient from the 'patient list' screen."

Few usability and design issues were identified. The strengths and weaknesses of the AEMR application expressed by the participating students are shown in Table 2. All participants indicated that they became familiar with the application with little effort and that the documentation functions were valuable. They said that the application structures were more intuitive and that it was easier to find patient information more quickly and accurately than on PC EMRs. The participants expressed concern about the possibility of losing data that they had entered when they left the form to find additional data.