Current & Future initiatives

Can EHRs be made more user-friendly for all nurses?

Making the EHRs more nurse user friendly is a challenge for the future. Blogging is a way for nurses around the globe to express their concerns, triumphs, failures, and successes with fellow nurses. As we talk about EHRs and nursing documentation, many nurses express their struggles with the demands of electronic charting. This system of computer information technology was designed to promote safety and efficiency, but can it also be designed to decrease the time necessary for nurses and other clinicians to input information?

There have been numerous studies done to determine the impact of electronic charting. It can be concluded that EHRs have improved efficiency of health information retrieval and improve patient safety, and thereby improved patient outcomes. It has also saved institutions in reducing administrative costs and reduce costs associated with medical errors. From a business perspective, EHRs are good for  business. However, if you ask those who have the task of inputting data into these EHRs, many would agree that the task is cumbersome. Bedside nurses, in particular, are feeling the burdens of electronic documentation requirements.

Documentation is a vital component of a nurse’s shiftwork. Nurses are trained that if it’s not documented, then it wasn’t done. Equally important is the quality of that documentation. Yet many floor nurses struggle to meet the demands of charting requirements. Studies that evaluate the time nurses spend on charting are often based on ICUs and OR settings that don’t give an accurate depiction of all nurses’ workloads. In ICUs for example, the patient to nurse ratio is 1:2 or 1:3 at best. On the other hand, the floor nurse can have up to six patients in one shift. There have been reports of nurses even caring for 8 patients at a time in a hospital setting. Secondly, many ICUs, ORs, Cath labs, and other specialized areas have built in templates that make documentation more efficient. A few clicks, a few ad libs here and there, and they’re done.

Insult was added to injury, when focus charting was implemented in the early 2010. Some nurses jokingly expressed it was like a writing a school report every day. Focus charting begins at patient admission to the hospital and requires the nurse key in on at least two nursing diagnosis focus points relative to each individual patient.

At the Atlanta VAMC, where EMRs and BCMAs have been in operation since 1994, Quality Management and Quality Improvement nurses monitor nursing documentation to ensure certain quality measures are met. Oftentimes nurses are remediated when documentation are found to be subpar. Erroneously these QI monitors assume that the problem lies in the nurse’s ability when the real problem is that the workload does not allow for the capacity of what is being expected. A nurse that has seven patients does not have the time to write a long paragraph for each focus point. Those dedicated nurse who do document to these standards often stay past their shift to complete them. Others find workarounds that result in poor quality charting. Both of these scenarios have legal implications.

So, can EHR systems be made to be more nurse friendly for all nurses? It certainly can be achieved. Nurses must be willing to be influential enough to produce change. Traditionally EHRs were designed with the health care organizational goals in mind which probably did not have the nurse at the center of that. Goals associated with reimbursements and compliance were at the heart of early initiatives. Somewhere down the line, efficiency got thrown in. These systems were designed by non-clinical, non-nursing personnel. Nurses had little or no input into them. Nurses realized that in order to make EHRs better, nurses needed to get involved in computer information technology to effect necessary changes. Today, we nurses have come further than ever in terms understanding that our electronic systems can do more to help us communicate, plan, practice, implement, and research new possibilities.

What if nurses had access to speech recognition devices or software for charting? We can talk into our smartphones and it will translate our voice messages into written transcriptions. Providers use an assistive device called dragon to dictate their notes. Proofreading after dictation is required for accuracy, however, this could tremendously cut down the time taken for charting.

Modifiable templates for all nurses is another consideration. Templates should be built for Focus and DAR charting. These templates or software should be loaded with every possible nursing diagnosis, intervention, plan, and possible outcome so to eliminate the need to be physically typed in a narrative. The software should also allow for free texting so that nurses can interject additional pertinent information into the chart. Again, this could greatly reduce time spent at the computer.

Finally, standardizations of the use of medical equipment that automatically uploads patient information into the EHR is vital. This sole implementation could reduce duplicity of nursing work, eliminate the possibility of inaccuracy due to manually transcribing into EHR, and create more time for the nurse to do other important tasks. There nurses and nursing assistants who still have to take a vital sign machine into a patient room, take the vital sign measurement, write it down on a piece of paper, walk back to the nursing station, and then enter it into the electronic record. All those steps were even exhausting to write.

In conclusion, the role of the nurse informatics specialists has enormous importance on how nurses can utilize technologies. The future is bright with many possibilities to make the EHR more nurse efficient. Nurses need to be aware and be willing to impress upon the powers to be to implement these changes. Standardization of these practices should have no barriers, including lack of technological equipment, software, and literacy. We owe it not only to ourselves to improve the way we utilize EHR for documentation but the future generation of nurses that will come after us.