Tuesday October 22nd 2019

Collaboration is key

Nurse experts discuss challenges, pose solutions

It really shouldn’t feel like a modern-day contest of man versus machine, but nurses are often frustrated about completing or finding relevant information in patients’ electronic health records, according to some nursing informatics experts.

But EHRs are here to stay and, if designed correctly, they can boost patient safety — whether it’s alerting health care professionals to a patient’s allergy, tracking quality measures, or preventing gaps in care as patients move from one setting or provider to the next. So nurse experts believe direct care nurses, nurse informaticists, administrators, information technologists, vendors and other stakeholders must work together to identify problems, and in turn, develop solutions to ensure all EHR systems throughout the country are more user-friendly, safer and can effectively communicate with each other across health care settings.

Identifying some issues

Documentation has always been a time-consuming process for nurses, and EHRs don’t always ease that process, experts say.

One anecdote that pioneering nurse informaticist Nancy Staggers, PhD, RN, provided involved a Maryland hospital where concerns were raised over the length of time it was taking nurses to document patient admissions into the EHR.

To address these concerns, a nurse informaticist followed a nurse who was inputting required information for an admission assessment. What the informaticist discovered was that the documentation process required 532 mouse clicks and scrolling through 14 computer screens, and took about 30 minutes to complete. Further, many of the data fields that nurses spent time clicking through were for the benefit of other departments, such as quality improvement; in other words, the EHR didn’t focus on critical nursing-related data.

Another example — one of several Staggers shared with colleagues at an April 2015 Health Information and Management Systems Society conference — involved the poor design of an electronic medication administration record screen. Specifically, nurses had difficulty obtaining the “big picture” of medications for a patient. They had to scroll extensively to see if any medications were missed, to see what was due, to click notes to check for pertinent information and to mentally connect  reported symptoms to potential medication issues. In another example of documentation issues, nurses were missing required charting of critical lab results, because the field that allowed them to input results was not visible on the single screen. (The screen display had been designed by a programmer using dual screens, although users had only a single screen.)

Nancy Staggers

“It seems so basic, but these problems do exist,” said Staggers, a health information consultant, adjunct professor in biomedical informatics and nursing at the University of Utah, and Utah Nurses Association member.

Also some of the charting fields are not tailored to the appropriate medication, she said. For example, a nurse might find options for charting a dose of acetaminophen include “given IV” or “left buttocks.” That undermines the credibility of the system, Staggers noted.

Patient safety is another key issue.

“It’s easy to miss critical information about a patient, because it can be buried in some area of the EHR,” Staggers said.  And in some facilities, nurses might not be using bar code medication administration technology on all units or departments. So a nurse might have to dig through paper or other computer-based documentation to find when a last dose of a medication was given if it was administered in an area, such as radiology or dialysis, that might not be using BCMA.

Linda Harrington

“Staff nurses know all the problems [with electronic documenta­tion], but they don’t necessarily know all the risks,” said Linda Harrington, PhD, DNP, RN-BC, CPHIMS, FHIMSS, a nursing informatics expert and Texas Nurses Association member who previously served as the chief nursing informatics officer with Catholic Health Initiatives, Texas Division, for many years.

“I followed nurses using bar code medication administration at one facility, and the biggest issue they had was lots of scanning failures,” she said. “Because they had to get those meds out within 30 to 60 minutes to maybe five, eight or 10 patients, they started doing workarounds. When they were not scanning the patients’ wristbands, they were
unintentionally circum­venting any safety alerts. They were just trying to get their medications completed on time in large part to stay off the automated report to their managers on late medications.”

Beyond acute care

“EHR-use in nursing homes is becoming more widespread,” said Gregory Alexander, PhD, RN, FAAN, a professor at the University of Missouri Sinclair School of Nursing, nursing informatics expert and Missouri Nurses Association member. “But it doesn’t mean that the EHR is being used by all staff. For example, in many nursing homes only certified nursing assistants use it. And clinicians use disparate systems.”

To gain a greater understanding of who is using EHRs and the extent of their use, Alexander is currently recruiting 10 percent of nursing homes in each state — roughly 1,600 nationwide — to participate in an ongoing Agency for Healthcare Quality and Research-funded study.

Alexander also wants to determine how well electronic documentation is being integrated internally and externally. For example, is the EHR in the nursing home well-linked to the lab?

“The ability of a nursing home EHR system to communicate with an external EHR system — like the local hospital — is very important in transitions in care,” Alexander said.  Yet one of Alexander’s other studies revealed that nursing homes that implemented health information technology generally did not use it to communicate with external entities, such as hospitals or off-site pharmacies. Poor IT integration with external stakeholders, such as hospitals, can create information gaps for admitting nurses who are coordinating care of newly admitted patients. These gaps can create more work, wasting precious nursing time while nursing staff attempt to fill information gaps in existing documentation. Furthermore, poor IT integration creates increased risks for delayed care for patients who need timely treatments or medications.

And even when that exchange of a patient record was possible, the resulting electronic documentation looked vastly different, he said. As a result, it was challenging and time-consuming for long-term care clinicians to find the information they needed.

Change and advocacy

Harrington isn’t surprised by the frustration of nurses and other clinicians when it comes to navigating EHR systems. People who are very comfortable using smartphone apps, email and word processing don’t understand why they can’t use an EHR just as easily, she noted.

“But an EHR is different,” Harrington said. “I frame it as a complex software application, which is something most people have never used before. That said, people don’t need more and more training, which is only adding to their cognitive overload.

“We need to make EHRs so intuitive to learn,” she said. EHR systems also tend to be implemented using a piecemeal, project-based approach, instead of thinking about nursing and how technology can support nurses in doing their jobs.

Staggers stressed that the next generation of EHR systems must be more interdisciplinary and patient-centered, as well as have improved usability and interoperability (the ability of systems to seamlessly communicate with each other).

Further, technology, such as BCMA, should be available house-wide to ensure that critical medication is not missed when a patient receives care in another unit or department.

Harrington also thinks it’s crucial that nurses report any issue they encounter with the EHR to key personnel, such as nurse informaticists or patient safety committee members, instead of creating workarounds. “Nurses have a right to have technology that supports their work, not adds to it,” she said.

Sentinel medication events involving EHR designs that are uncovered by nurses also could be sent to a central, agnostic repository (that needs to exist), as well as to all vendors and to pertinent health care sites, Staggers proposed.

She also agrees that nurses must take an active role by speaking up locally and nationally — such as testifying before Congress — about the critical issues they encounter with EHRs. For instance, nurses can advocate for the formation of a national organization to address patient safety issues and to create design and workflow solutions.

“Nurses are the largest group of EHR users in the nation, so why wouldn’t our voice be heard?” Staggers said.

Another EHR “intervention” involves testing of technology solutions.

Nurses, particularly those who will actually use the EHRs, must be involved in the purchasing, usability testing (before purchasing) and tailoring processes. Further, usability testing before purchasing should apply to all technology, including IV pumps, and poor usability results can be included in the contract for resolution.

Roles and partnerships

The role of nurse informaticists needs to evolve, Harrington said.

“Implementation and training is not the skill set that is needed today,” she said. Rather, nurse informaticists must be able to facilitate discussions between staff nurses and nurse analysts who work in information technology to ensure the right questions are being asked so solutions can be effective.

“Staff nurses can tell you the problems,” she said. “They just don’t know how to solve them on their own.”

In terms of long term care needs, Alexander said standardizing electronic documentation is key.

“The basic tenets of patient care are the same in acute care and long term care — it’s the nursing process,” Alexander said. So nurse representatives from both groups need to help guide the standardization of electronic documentation to increase interoperability.

Finally, Staggers said improving EHR systems is a joint responsibility between vendors and health care organizations — with strong input from nurses and others who rely on them to provide quality, safe patient care.

“It’s like an arranged marriage,” Staggers said. “You need to make it work for the sake of the family.”

— Susan Trossman is the senior reporter for The American Nurse.


To read ANA position statements, go to nursingworld.org/ANA-Position-Statements

  • “Standardization and Interoperability of Health Information Technology: Supporting Nursing and the National Quality Strategy for Better Patient Outcomes”
  • “Inclusion of Recognized Terminologies within EHRs and other Health Information Technology Solutions”
  • “Electronic Health Record”

OJIN articles: Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings published April 14, 2015

Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses’ Experiences and Attitudes – Survey I published Feb. 25, 2011

The NLM Nursing Resource for Standards and Interoperability site:

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