6 comments

3 EHR improvements nurses most want to see

  • Kerry D. Bruning, RN, BSN, MBA
  • 05/07/2015

HIMSS Analytics conducted a survey of nurses, uncovering what they like (and what they don’t like) about electronic health records (EHRs).

One of the results shocked me: about 15% nurses wanted to go back to paper-based medical records, and another 15% said they weren’t sure if they’d go back or not.

I flashed back to my experience as a pediatric oncology nurse on the night shift. For example, when a patient’s fluid intake and output didn’t match up, I had to figure out if it was a miscalculation. I could spend 90 minutes poring over a spreadsheet trying to find the math error.

It got me thinking. Where are EHRs coming up short? What makes nurses want to return to paper? Based on the top three reasons indicated in survey results, I have a few theories:

1) Easier to find information

Nurse survey respondents who want to return to paper charts said it was easier to find information that way. Ironically, the majority of nurses who would not return to paper say that it is easier to find information in EHRs.

It’s clear that nurses agree that access to information is vital for patient safety.

My guess is that nurses who find paper easier to navigate than EHRs likely have a workflow design problem. If an EHR view does not exist where nurses can see their top five or six things, then nurses need to speak up and change it.

2) More focus on the patients

Nurses would much rather spend time with their patients, not on documentation. The second most common reason they gave in the survey for wanting paper records is that EHRs detract from focus on patients. Again, this could be a workflow issue.

It could also be that people aren’t remembering the time-consuming aspects of paper-based records. For example, many of the pediatric units where I worked required us to keep patient charts at the nursing station. We spent lots of time going back and forth (taking time away from the patient). Hunting for missing charts also took time away from the patient.

3) Faster data entry

It might be easier to scribble a note in a paper chart rather than finding the right place to document in the EHR. But is paper documentation better for patients and the entire team of caregivers?

Nurses who would not go back to paper cite “handwriting issues” and “allows for complete entry” as two significant reasons why they prefer EHRs. The EHR forces a clearer, more complete form of communication. Yes, it might take more time up front, but it can save time in the long run.

Years ago, when paper dominated medical records, we managed new regulatory requirements by adding new forms. Need to do skin checks? Add a flow sheet. Need to start doing fall-risk assessments? Add another flow sheet. Given the increasing complexity and demands of today’s regulatory environment, I shudder to think about trying to manage it all with paper charts.

Maybe some of these nurses have never worked in a paper-based environment. Maybe they have forgotten. Maybe their EHR isn’t working as well as it should. But I remember very clearly the limitations of paper. I agree with the majority of survey respondents that EHRs are helping to improve patient safety.

To all my fellow nurses out there during Nurses Week, thanks for all you do. I’d love to hear your thoughts on this subject in the comments below.

Want more detail about the HIMSS Analytics Nurses Survey? Download a free white paper or check out this infographic.

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About the author

Kerry Bruning has been with Allscripts since 2010 and is a Director of Marketing for the Payer Life Sciences team. Prior to this role, she led a team of professionals supporting the global hospital and health systems solution, Sunrise. Their mission is to raise awareness of the uniqueness of the Sunrise EHR, which was developed around the concept of providing decision support to clinicians. Prior to her role with Sunrise, Kerry worked with other large and small EHR vendors in multiple capacities, from demonstrations to implementation, training and solution development. Kerry became passionate about IT technology in health care during her experiences in hospitals. As a pediatric nurse as well as a nurse manager, she learned how EHRs could help or even hinder clinicians in their goals to provide the best care to their patients. She also learned the extreme importance of patient and family engagement in their health care and the impact engagement can have in health outcomes. Outside of work, Kerry relaxes with her husband and horses, and champions causes for animals, as well as children who can benefit from relationships with animals.

6 COMMENTS on 3 EHR improvements nurses most want to see

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Ellen says:

05/12/2015 at 5:59 am

Really? You want nurses to speak up??? Is that because in the history of nursing it has shown that nurses speaking up has affected change??? The doctors I work for speak up all the time but when it comes to change within the EHR it generally falls on deaf ears.

I want to live in whatever fantasy land that you live in!

Kerry Bruning says:

05/12/2015 at 9:37 am

Hi, Ellen – I appreciate your frustration – it’s evident you’ve had experiences where you and your peers weren’t listened to. I admit to being an optimist but, even if I weren’t, we still need to push as a profession to ensure these solutions support us and the patients we serve.

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Sandy says:

05/12/2015 at 2:37 pm

Five years ago, out of total frustration, I conceived the idea for the msPad, to help increase speed, accuracy and efficiency while doing data entry.
Before proceeding with the idea, I surveyed over 500 end users. I literally had a 100% positive response.
I started on my journey. I currently have a registered trademark and Notice of Allowance from the USPTO.
I have contacted virtually every EHR vendor in the US, attempting to have the msPad incorporated into their EHRs. But, as mentioned above, when it comes to change within the EHR it generally falls on deaf ears.
I am currently working with PAPPS (Parallel-Processing Apps) to have the product developed and marketed.
Just wanted to voice my two cents worth.

    Tina Joros says:

    05/15/2015 at 11:47 am

    Hi Sandy – your msPad solution looks like it would be a good fit for our Allscripts Developer Program (ADP). This program was designed to support the integration of innovative new technologies with our Allscripts EHRs. You can visit http://developer.allscripts.com to begin integrating today, explore our Allscripts Application Store at https://store.allscripts.com for more information on current solutions available or I’m happy to set up a call with you to provide more information on our program and how you can get started.

    Tina Joros | Director – Allscripts Developer Program

    tina.joros@allscripts.com

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Daylanne Sheehan says:

05/13/2015 at 7:10 am

I’ve worked both in paper and EHR and generally embrace technology but know that there was an ease in finding info that is missing in the EHR and I’m not convinced it relate to a design issue or not. I suspect it’s more due to the requirement for the user to memorize locations of info in an EHR that is not needed on paper. The steps often follow a pathway that reflects how a software designer’s brain works which is not necessarily the way a seasoned nurse thinks. For example, the new user might have difficulty locating med education when our software requires tabbing from care management to evaluate THEN to med education, REALLY?!
My primary issue w/ the EHR is the greater amount of time required for data entry is time focused on a device, NOT a person/patient. It demands attention, is not warm, caring, compassionate and physically places a barrier between me and my patient. And often even requires the nurse to turn her back on her patient or their family. You admit it requires more time up front. Unfortunately, this is the time of establishing rapport when patients are under the greatest amount of stress and nurses are required to focus on an electronic device. I’m suspecting we are shortchanging out patients.
Faster data entry is a fallacy in my world, PERIOD.
The real advantage to an EHR is the ease of data retrieval for compiling reports and justifying billing. Yes, medication administration systems reduce errors and improve safety while assisting w/ charges, but for the vast majority of nurses, the EHR continues to be a cumbersome tool we are required to use that takes precious time away from hands-on caring for our patients and puts our hands on a keyboard.

Kerry Bruning says:

05/13/2015 at 12:42 pm

Daylanne,

I agree with your comments. As to your primary issue (and you point out very well) faster data entry is a fallacy. In fact, it shouldn’t be the goal as it sets the wrong expectations. We should be focusing on quality and safety – medication administration isn’t faster with bar-code capabilities, but it is safer. Documentation isn’t faster, but it provides decision support engines information that can better help us do the right or best thing for our patients.

The ‘barrier’ issue you raise needs to be resolved. Strides are being made in mobility, which should help reduce the physical impression of a barrier, but we also have to make strides in usability and workflows that require less attention from you as you document. In the meantime, have you tried including your patients and their families? Perhaps positioning yourself with your EHR in a way that they can see what you’re doing and ‘help’ you complete your documentation? It doesn’t work in every instance, but can help reduce the perception of the EHR being in the way.

Your insights as to why it’s easier to find information on paper versus electronic has me thinking. With paper, even in big critical care flowsheets, we have a defined 24-hour view. Everything is always in the same place and, even if we want to go back to the previous day, we know exactly where to look. It’s all in neat (well, maybe) predictable buckets.

The inherent flexibility of EHRs – with flowsheets even differing based on what’s needed for the patient – and the access to the complete continuum without those well-defined buckets does make it harder. Will we ever solve that? Is it because, for both of us anyway, we grew up on the paper paradigm, and we’ll always consider computers a second language? Given the success of smart phones, I don’t think so. We need to innovate EHRs in the way that that industry has transformed our communications experience. We need to champion innovation for nursing.

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