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Discussion 250 words minimum and 3 references

Read the

Stokowski article

from Week 3. Consider the implementation of the EHR in your facility. After reading the article choose one issue or argument presented. Answer the following points:

Discuss how you encountered this in your facility.
What were the common responses of staff and providers? What were the barriers and how could you overcome them?
Consider how you would have changed the implementation and/ or ongoing support for the EHR. What specific measures or support would you have provided and why?
How can you evaluate the effectiveness of the measures?
If you could tell your head of information technology how to improve it or change, what would it be and why?

www.medscape.com

Electronic Nursing Documentation: Charting New Territory
Laura A. Stokowski, RN, MS Sep 12, 2013

Nurses Speak Up About Electronic Charting

Back in the days when computerized documentation was still a pipe dream and we had callouses from so much writing, nurses often grumbled
about charting. Here is a familiar observation: “In spite of the apparent importance of charting, it is probably one of the greatest ‘hates’ of nurses.
Many nurses complain that the time spent in charting might be more profitably used in actual patient care.”[1] Although made in 1928, this
comment could just as easily have been made today.

Not long ago, we posted a short article, Staying Late to Chart: Is This Legal? that clearly hit a nerve with nurse readers of Medscape. The article
prompted more than 400 comments and letters to the Editor about the problems nurses were having with electronic documentation. To find out
how widespread these problems were, we posted an informal survey asking nurses a few questions about their experiences with electronic
documentation. More than 7000 nurses took our survey, and 750 commented.

We took these comments to experts in the field of electronic documentation to get their thoughts and ask for their advice. This article represents
what the Medscape readers, and the experts, had to say about electronic documentation and nursing practice, and what nurses may expect from
the future.

Advantages of Electronic Charting

Electronic health records (EHRs, also known as electronic medical records) have distinct advantages over paper. Mentioned most often is the not
insignificant benefit that provider orders are legible and clear. Nurses no longer have to waste time consulting with one another, trying to decipher
someone’s dreadful handwriting, and fewer errors related to misinterpreted orders should follow. Nurses also like being able to find information
about previous episodes of care (hospitalizations or visits) easily and having all information about a patient integrated in a single place.

A reader said, “I love our hospital’s computer system. It is easy to use and covers all the bases. Although there is some repetition, it is getting
much better, as improvements are constantly being made. I would never want to go back to paper.” Overall, most nurses who took the survey
either “loved electronic charting” (45%) or reported that they “were getting used to it,” and believed they would eventually like it (26%). Although
16% were undecided as to how they felt about EHRs, only 13% reported either having a hard time with electronic charting or said they wanted to
go back to paper charts.

Ward and colleagues[2] conducted a survey of nurses to determine whether they perceived alterations in quality of patient care, clinical processes,
workflow efficiency, communication, and flow of patient information after EHRs went live in a hospital setting. At 6 months after implementation,
the areas that improved the most were:

• Communications when patients were readmitted or received follow-up outpatient care;

• Access to information improving the ability to make good patient care decisions;

• The timeliness with which patient-related data are available; and

• Legibility and clarity of patient care orders.

Computerized provider order entry (CPOE), implemented along with EHRs, is another feature that has the potential to improve clinician workflow,
efficiency, and patient safety.

There Is a Downside, Say Nurses

Unfortunately, some nurses still feel that these gains are overshadowed by the perceived disadvantages of EHRs. Even those who can see the
benefits and potential of EHRs identified persisting issues that can negatively affect patient care. Although many of the problems encountered by

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http://www.medscape.com/viewarticle/804934

http://www.medscape.com/viewarticle/807223

nurses in a wide range of healthcare settings are specific to the design and functional characteristics of whichever EHR system was purchased
and implemented in their work settings, other problems are more universal. These issues can be grouped into the following categories:

• Documentation time;

• “Check-box charting”;

• Point-of-care and real-time documentation; and

• Logistical and design issues.

EHRs Take Too Much Time

Before EHRs were implemented, they were touted as a huge step forward in patient care. They were supposed to be more accurate, safer,
timelier, and faster. Computers were going to free up nurses to spend more time with patients.

Instead, report many nurses, documentation is taking longer than ever. One nurse believes that since going live, EHRs have added 3 hours to a
12-hour shift. The extra time that EHRs take has many origins — endless logging in and out; paging through unnecessary screens; duplicate
entries; trying to find where to chart something; slow, cumbersome systems; and increased mandatory documentation. The latter complaint was
frequent. One nurse commented that EHRs require nurses to chart not only what they did, but also what they didn’t do — for example, “didn’t put in
a Foley.” With computers in the patient rooms, nurses often can’t concentrate on the task at hand; they are constantly being interrupted by
patients and visitors while they are trying to chart, and consequently, charting takes longer.

To save time, some healthcare providers take advantage of the “copy-and-paste” feature of EHRs, which might be a double-edged sword. If the
person who copies and pastes does not verify every word or data point, it is alarmingly easy to perpetuate errors in the chart, a problem that many
readers have already identified in actual patient EHRs.

And the time saved by CPOE in not having to write verbal orders, or interpret illegible orders, has been lost in other ways. Some nurses report that
CPOE has reduced face-to-face communication with physicians, so they have less understanding of the plan of care for patients, and they spend
more time double- and triple-checking orders to make sure they don’t miss something.[3]

The extra time that it takes to chart with EHRs must come from somewhere. Fundamentally, nurses do not consider documentation time as time
spent providing patient care.[4] Knowing that they will be judged on their documentation rather than their care, many nurses feel that patient care
has suffered. One nurse even said (tongue-in-cheek), “In reality, we don’t need to do anything at all for the patient, as long as we document that
we did.”

A far more common complaint is that “we are nursing the chart rather than the patient.” “I never thought I would see the day when a machine
would need to be cared for more than my patient,” commented a nurse. But rarely has staffing improved to compensate for the increase in
documentation time. “We have the same nurse-to-patient ratios as always, but signing in and out of a computer and documenting every little thing
we do takes so much more time. That time is taken away from patient care. It’s pathetic to see us all lined up at computers instead of caring for
patients!”

Or lining up at computers after the shift ends. Our informal EHR survey found that in the past 6 months, 72% of respondents had stayed after their
shift to finish charting (46% occasionally, 24% frequently, and 9% almost every shift). Although more than one half of respondents were paid, 21%
said that they were “off the clock” when they stayed late to chart. A nurse practitioner wrote, “You have the choice of garbage in and getting out on
time, or doing a decent job and working longer but uncompensated.”

Reasons given by readers for not being able to complete their charting by the end of the shift were fairly evenly divided between insufficient
staffing (too many patients for each nurse), too many other responsibilities and interruptions, and unrealistic/excessive documentation
requirements with EHRs. Six percent of respondents blamed computer access problems. Inefficiency or poor computer skills were cited by less
than 1% of respondents, despite the fact that 55% of the respondents were older than 50 years.

Perception, Reality, and Learning Curves

Does EHR documentation really take longer than paper charting? Yes and no. In a before-and-6-months-after implementation survey, nurses
reported that they were spending more time documenting patient care and less time directly with patients.[2] In some cases, this might be a
consequence of first recording data on temporary notes and then transcribing data into the computer.[5] In earlier studies, nurses reported
spending a median of 50% of their time using electronic documentation systems.[6] Results of other studies that evaluated whether electronic
documentation is more time-consuming are conflicting.[7]

In one of the few recent studies to examine this question objectively, Yee and colleagues[8] assessed time spent by nurses documenting on EHRs
compared with paper charting. A cross-sectional analysis was completed using time-and-motion data from 105 units in 55 hospitals. They found
very little difference between time spent documenting with EHRs or with paper-based charts. Nurses spent 19% of their time completing
documentation, regardless of method. These findings suggest that integrated electronic medical records and computerized nursing notes do not
increase the time nurses spend charting. Whether such findings are generalizable to other nurses in other settings is unknown.

What is the truth? Is this a case of perception trumping reality, or haven’t we allowed sufficient time to pass for nurses to become efficient in the
use of EHRs? According to our informal readers’ survey, one half of respondents have used electronic documentation longer than 3 years, and
one third from 1 to 3 years.

In their observational study, Cornell and colleagues[9] found that some nurses reported spending up to 60% of their time doing computer
documentation, but these claims were not confirmed by observation. It is possible, of course, that we are more likely to hear from nurses who are
having trouble adapting to EHRs or who are more concerned about the quality of documentation, and therefore spend more time on
documentation than the average nurse. However, if one fourth of nurses are “frequently” staying after the end of their shift to complete charting,
clearly, something is amiss.

Although nurses generally acknowledge the potential of EHRs to improve safety, many also feel that in times of competing priorities, patient care
has to come first. A nurse who designates charting as a lower priority said, “I rest easy at night knowing I didn’t sacrifice bedside care to click
boxes on a screen.”

Fortunately, experience suggests that, over time, nurses become more efficient and spend less time documenting on EHRs. Willa Fields, DNSc,
RN, Professor of Nursing at San Diego State University, explains that mastery occurs between 4 and 8 months after the implementation of an
electronic system. “With the traditional paper chart, you had a mental picture of how things worked and where they were located. You didn’t think
about the time you spent flipping pages. You knew where to find things. EHRs require a new mental model that isn’t yet synthesized. It’s not
actually disorganized; it’s just that you haven’t learned it yet. When you achieve that mental picture, you will zip right through it.”

Too Many Check Boxes, Too Little Narrative

What’s going on with the patient? The ability to read a patient’s “story” is highly valued in healthcare, not only by nurses but also by clinicians in
many other disciplines.[10]

Following the advent of EHRs, many nurses expressed dismay at the loss of space in the patient record to write narratives, to tell a story about
what is happening to the patient and what occurred in the course of care. Such narratives are considered to be essential for communication
between members of the team of healthcare professionals taking care of the patient. Although some like their ease of use, many nurses feel that
“check boxes” and menu items don’t sufficiently capture this element of care, and that limited comment fields are inadequate.

It’s true that structured drop-down menus, a prominent feature of EHRs, are very different from paper records. But do such menus improve or
detract from the quality of documentation and, by extension, the quality of patient care? Drop-down menus with a panoply of choices could aid
nurses by not requiring them to rely on memory for what should be assessed and documented.[6] On the other hand, picking items from a menu,
rather than using critical thinking to determine what is important to a particular patient’s care, could also impair the development of those higher-
level skills. Furthermore, selecting only from a menu could limit the full description of the patient’s clinical status,[7] as we heard from Medscape
readers.

“I miss the freedom of being able to describe something in my own words vs trying to put my patient in a box. Too much clicking takes the person
away, and makes it too easy to overlook something or click the wrong box,” wrote a nurse. Another nurse is concerned about accuracy in check-
box documentation, finding widely different assessments of the same patient by consecutive nurses who checked different boxes.

Another nurse explained why check boxes fall short when it comes to documenting unique aspects of care. “I was trained to use professional
charting to document the patient’s status, what I did, and the outcome and new or continuing plan for care. All this is lost in the check boxes that
now define and measure care and outcomes, and shape how we think about care. My patients are highly variable human beings. I want to
document as a professional, not as a robot checking boxes. It is hard to get a good picture of the information that is there, because it is scattered
over multiple screens, and it takes a long time to gather. I cannot see it all lined up together and integrated.”

But how important are narrative notes, really? Research shows that only about 38% of all healthcare provider notes, and only about 20% of
nurses’ notes, are read by anyone, ever.[11] Unless the note truly fills a gap in documentation by communicating something that does not exist
elsewhere in the record, is writing notes a good use of the nurse’s time?

We heard from some people who do read EHR documentation. Here is a sampling of comments about what it is like to try to review a typical EHR:

• “It is very difficult to find needed information in the EHR. What I see is either conflicting documentation or more often, no documentation. A
patient is transferred from med-surg to ICU and there is no documentation about the change in condition, interventions, or contact with physicians
— the patient is just suddenly in the ICU. I would hate to be the nurse trying to defend what I did for the patient prior to transfer to a higher level of
care, because the EHR looks like nothing was done.”

• “Having had to do quality-of-care reviews, I can truly say that there are instances when after reading the entire record, I still cannot tell what went
on with the patient.”

• “I review charts for complaints against nurses and doctors. It is very difficult to ascertain what is happening with a patient because everything is a
check-off. When patients go bad, it can be very difficult to prove or disprove that appropriate care was done at the right time. EHR charting can be
a way for hospitals to omit facts.”

Another nurse who reviews charts described a nightmare of pages and pages with random numbers or words printed on them, impossible to place
into context. No wonder nurses are worried about the elements of documentation that seem to have disappeared with EHRs, and their ability to
defend their care on the basis of their documentation. Furthermore, many nurses are concerned that “charting by exception,” which is more
prominent with the advent of EHRs, is inadequate. However, charting by exception, when supported by hospital or unit documentation policy, does
meet the legal standard of care for nursing documentation.[12] So does checking off a box that says “within defined limits,” as long as these limits
are defined in policy and procedure.

Still, some nurses believe that EHRs take point-click and fill-in-the-blank charting too far, making more work for the nurse. For example, a nurse
complains that they now have to enter systolic, diastolic, and mean values in separate fields, which takes more time than jotting down a blood
pressure. Some nurses find the descriptor choices inadequate for such items as wound assessment or pain.

The lack of prompts and free-text fields for narrative charting on EHRs is not accidental. EHRs are most useful to healthcare facilities when the
data are entered into discrete fields, allowing the data to be aggregated, sorted, and manipulated.[13] Free-text data can’t be easily extracted; a
manual auditor is required to search narrative fields for the desired data. If your system restricts your ability to enter comments, it is likely that this
was a deliberate design feature of the EHR.

Joyce Sensmeier, MS RN, Vice President of Informatics at HIMSS (Health Information Management Systems Society), provides a perspective on
this issue. “The initial wave of EHR systems included a lot of check-box approaches, replicating previous paper-based systems. Looking to the
future, the next round of EHRs will optimize how we document, so it isn’t just a check-box approach but focuses on telling the patient story. A pilot
study[10] has been done showing that it is possible for the EHR to pull relevant data from the history, key problems, diagnostic results, and events
during the hospitalization, into a dashboard that allows providers to see the patient story at a glance when they open the record.”

The dashboard could solve the “what has happened to this patient?” problem, but what about the “what has happened during my shift?” story that
many nurses used to tell through detailed narrative notes in the paper record?

“The ‘story of my shift’ is what we wrote because all we had was paper and pen, but it’s becoming irrelevant,” says Sensmeier. “No one reads
those narratives. We have to get past documenting that way and move to outcomes. We need to show the impact of nursing care — the patient
improving or not being readmitted because of what the nurse does. We will always need a certain amount of free text, but we can’t use all
narrative or we won’t be able to look at these outcomes.”

Changing Nurses’ Workflow: Real-Time Charting

“We must remember that the EHR is a tool; it should not dictate how we practice,” wrote a Medscape reader. Perhaps it should not, but does it?

The fact is, EHRs are far more than a method of entering data — or a digital version of the patient care flowsheet. EHRs are sophisticated clinical

information systems that extensively alter nurses’ workflow and processes of patient care.[2]

Probably the single most significant effect on workflow prompted by EHRs is the shift to point-of-care and real-time charting. Experts in nursing

documentation have always recommended that charting take place as near in time to the actual event or episode of care as practical — nothing

new there. However, a key premise of EHRs is to make patient care data immediately available to the entire healthcare team so that it is accurate

and actionable. To not do so negates an important advantage of electronic documentation.

With this in mind, the fact that many nurses are staying after their shifts to chart represents a disturbing trend that should make hospitals sit up

and take notice. Millions of dollars are spent to implement and maintain an EHR system — far too much for it to be used only as an expensive

substitute for paper. So, are nurses just unable to adapt to real-time charting because it is so different, or are patient loads too heavy to permit this

pattern of charting?

Nurses who commented for the charting survey were divided on this point. One nurse maintained that “A significant number of staff never learned

to chart as they go and instead wait until the end of the shift to chart. Now that documentation clearly informs all of this behavior, those nurses

have to incorporate what should have been ‘best practice’ all along.” Another nurse acknowledged her own difficulties with real-time charting: “It is

more my long-standing personal habit of not charting in the moment that is the biggest barrier than anything else — human behavioral change is

needed.”

However, far more nurses cited workload issues, such as insufficient staffing, excessive patient loads, and unpredictable and rapidly changing

clinical situations, as barriers to accomplishing real-time charting. For example: “Documenting as we go is the best, but I can’t write while my hand

is pushing in a chest or restraining a drunk who wants to kill himself in the ER,” wrote a nurse.

Charting has long taken a backseat to patient care, whether it is on paper or a computer. Traditional nursing practice has often been “patients first,

chart when I have time.” A 2010 study confirmed what many nurses are saying about their charting patterns, even with electronic documentation.

In observations of 29 nurses, Cornell and colleagues[14] found that nurses typically practiced “batch mode” charting, which involved accumulating

patient data and later entering it on the computer. EHR implementation does not appear to be leading to the demise of the “paper brain.”

Research and observations continue to find that nurses are attached to the use of informal and temporary paper notes or charting.Technology

alone may not lead to “a world of real-time information.”[9]

If nurses are unable to chart in real time because of high patient-to-nurse ratios and insufficient staffing, it makes sense to reassess workload and

staffing levels, but this doesn’t appear to be happening. Many nurses feel that administrators have failed to provide the nurse staffing and support

staff to match the sophistication and potential of EHRs. “As long as I have been a nurse, documentation has never been factored into the

workload,” said a 30-year veteran. Another said, “I need a stenographer to follow me around during my work and record everything I see,

discover, think, evaluate, and do.” Still another said, “I got a nursing degree, but I’m really just a data-entry clerk. I nurse a computer instead of a

patient, and it is made very clear that the computer input is more important than the patient.”

How important is it that nurses chart in real time? “Patients’ lives depend on it,” asserts Joyce Sensmeier. “Nurses are not the only ones who have

that chart now — everyone has it, and they all depend on it for up-to-the-minute information. We can’t wait to chart anymore.”

Point-of-Care Charting

Hand-in-hand with real-time charting is point-of-care documentation, representing another change in nurses’ workflow ushered in by EHRs. The
idea is that computer workstations would be located in patient rooms or wherever care is provided, enabling nurses to document care as it is
delivered. An inability to incorporate point-of-care documentation into nursing practice can threaten successful implementation of EHRs.[15]

In the past, nurses might document vital signs, intake and output, and other data on flowsheets or scraps of paper at the point-of-care, but the bulk
of documentation took place in centralized locations, such as nurses stations, or cubbyholes located outside of patient rooms. EHR documentation
has brought computers to the bedside and into the examination room. Charting in the patient’s room, however, has raised concerns.

Angie Kohle-Ersher is an information technology nurse who recently conducted a study that contained 2 surveys.[16] The first survey, which asked
nurses about impediments to point-of-care documentation, identified the following barriers:

• Location of the computers in the room. Nurses had to ask visitors to move, turn their backs on patients while charting, or chart standing up.

• Unreliability of computers in patient rooms — they are slower, and often freeze up.

• Privacy concerns: visitors looking over the nurse’s shoulder, reading the chart.

• Some patients dislike the nurse charting in room; patients interrupt with questions and requests.

• Some patients complained that the lights emitted from computer monitors disrupted their sleep.

Kohle-Ersher’s findings are supported by other research[5] as well as the anecdotal experiences shared by Medscape readers.

A self-described “mature nurse” dislikes charting while talking to patients. “I like to give the patient my full attention, with good eye contact. This is
very important for assessing the patient as a whole. A lot is missed when nurses (and doctors) stand at the computer and just go down the list,
barking out questions to fill in the boxes.” Another nurse concurs. “Some providers don’t even make eye contact with a patient because they are
focused on the computer. It takes some of good bedside manner away from the encounter.”

Kohle-Ersher has heard these concerns before. “Although point-of-care charting — when done properly, where care is delivered — is more
accurate and improves timeliness of care, nurses don’t yet see the value enough to change their workflow habits to accommodate it. In the study,
we found that having in-room computers has not changed the location of charting. Sometimes the in-room computers don’t work as well as
centralized computers. It takes longer to boot up and log on to them. Some patients will even complain about the lights of the computers when
used at night in the patient rooms.”

Kohle-Ersher’s second survey asked nurses to rate the priority of everyday nursing tasks. In most cases, documentation was rated at the lowest
priority of all nursing tasks. This finding suggested to Kohle-Ersher that nurses did not view point-of-care documentation as a high priority and that
it did not influence the timeliness of care, which she says is a false conclusion. “Documentation does affect the timeliness of care. When a nurse is
ready to give a premeal insulin dose but has to track down the nursing assistant first to find the patient’s glucose level, care is compromised.”

One proposed solution to this problem is computers on wheels/workstations on wheels (COWs/WOWs), although these can be difficult to
maneuver in crowded patient rooms. With COWs/WOWs, the nurse is able to coordinate with the patient’s care plan and incorporate nursing
interventions and assessments from the EHR, and collect data from the patient, all at the bedside instead of going to a computer at the nurse’s
station. Used in this way, the COW/WOW allows the EHR to adapt to, rather than disrupt, the nurses’ workflow.[17] “Anecdotally,” says Kohle-
Ersher, “nurses have responded well to WOWs, but we don’t know whether their use has actually increased point-of-care charting.”

Luann Whittenburg, PhD, RN, Chief Nursing Informatics Officer at Medicomp Systems, agrees that point-of-care charting can be difficult to
accomplish. “Sometimes the EHR doesn’t encourage the close proximity needed for event charting. We know that nurses are not in control of how
the day flows, so we need to give them flexibility to chart at or near the point of care. Some facilities are going to mobile devices, so there is a
greater probability of real-time/point-of-care charting.”

Whose Chart Is It, Anyway?

“The purpose of an EHR should be helping the end users (us) to be more efficient in charting and free up time for direct patient care,” observed a
Medscape reader. However, this nurse reflected, “this has not been the case.”

It is no wonder that many nurses feel that they have turned into data-entry clerks. Most nurses are strictly on the “input” end of EHRs, and have
little or no experience with the output. It is difficult to appreciate the value of the tremendous amount of information that is processed when all one
does is endlessly enter data,[17] especially if the data being entered don’t truly reflect what nurses do — in other words, nursing practice. “Systems
seem to be built for the collection of quality improvement data, meaningful use, and physician order entry, not for the ease of nursing
documentation,” commented a nurse. Another wrote (and others echoed the sentiment), “Charting is about money, accounting, inventory, reports,
and many tasks that have nothing to do with nursing.”

All of this begs the question: Do nurses and hospitals have different priorities when it comes to documentation, and how can they be brought
together?

Traditionally, the purpose of nursing documentation is to facilitate information flow that supports the continuity, quality, and safety of patient care.[2]

Over time, documentation has accumulated many other purposes. Even with paper charts, new forms were added from time to time to meet some
regulatory requirement or other. Now, EHRs have made it even easier for administrators, payers, reviewers, and government agencies to add
required fields to the EHR so that they can track data, overloading the nurse with documentation requirements.

“Many of the documentation requirements that are considered excessive by nurses were put into EHRs to meet Joint Commission standards for
core measures (eg, stroke, acute myocardial infarction, and venous thromboembolism) and to meet quality care measures for CMS [Centers for
Medicare & Medicaid Services]. As CMS reimbursement shifts from volume to outcomes-based reimbursement (value-based purchasing
programs), nurses can expect to see more required documentation,” explains Angie Kohle-Ersher.

Willa Fields acknowledges that the burden of nursing documentation, whether on paper or computer, has increased over time. She disagrees,
however, that such requirements are unrelated to patient care, and believes that nurses need to broaden their view of what they do, reminding
them of the tremendous value of their documentation to all patient care. “Patient care is more than what we provide to individual patients,” says
Fields. “The information that nurses document can be analyzed to identify opportunities for improvement both for individual patients and the
population at large.”

Luann Whittenburg believes that we need to bring the nursing process back to nursing documentation. Current EHRs, she says, have
disconnected the nursing assessment from the nursing process that supports nursing care decisions: nursing diagnoses, planning, interventions,
and outcomes.[19] “The future for the EHR involves expanding the capture of coded nursing data using a nursing language that follows the nursing
process for patient care. Nurses can then begin to tell a cohesive and accurate electronic patient story in an EHR.” At Medicomp, Whittenburg is
currently testing a system that will accomplish this by providing nurses with a single note space that is customizable for each organization and
works with other components in a nursing documentation tool.

From User-Unfriendly to Nurses’ Best Friend

It was clear from the comments made by nurses that many different EHR systems are in use today, explaining the high degree of variability in
functionality and user-friendliness reported by nurses. Some nurses complained of redundancy in required documentation, poor or nonintuitive
organization of screens, difficulty locating where to enter data, and other system-specific issues. Sluggish system operation was a frequent
complaint — slow log-on and loading of screens (possibly related to high demand), screens freezing in the middle of documentation, loss of data
(requiring the nurse to start over), and system downtime (requiring reverting to paper documentation) were sources of frustration with some EHRs.
Some nurses complained of frequent system changes and upgrades, and a lack of information technology support when needed.

At the same time, we heard many variations on the theme of “electronic records are here to stay,” such as this: “Electronic charting benefits the
patient and streamlines their care. Nurses need to get on board and be the advocates that support this change.” A nurse who moved back into a
setting with paper charting “realized just how much of an advantage even an imperfect EHR was” over paper. Another said, “Anyone who wants to
return to paper either hasn’t given EHRs a real chance or can’t remember the problems with paper — thumbing through charts to find what you
need, requesting old charts, finding the last space for a note taken and having to restock the chart before continuing, lugging charts up and down
the halls….”

Still, even nurses who favor EHRs over paper acknowledge that EHRs need to evolve, and there is much room for improvement. “I love the
potential for the EHR,” said a reader, “but currently so little is done to pull the power of computers into actual practice.” For example, many
systems don’t dump data from monitors and screening devices into the EHR in real time, a function that could be a significant time-saver for
nurses. Joyce Sensmeier has encouraging news. “Device data that automatically populate the EHR is where we are heading.”

Nurses value many aspects of EHRs, but usability is not yet where it needs to be. Nurses want an EHR that supports their work with integrated
patient information, and helps them provide efficient, safe, quality care.[19] Willa Fields agrees that EHRs aren’t as user-friendly as we need them
to be. “We have not solved the interoperability and usability issues of EHRs,” says Fields. “The EHR must complement and improve the nurse’s
work, rather than impede it.”[19] Fields encourages bedside nurses to seize the opportunity to be part of the design team when systems are
selected, configured, or upgraded. Her research shows that nurses also need education not only on the technical aspects of EHRs, but also on
anticipating and managing the inevitable changes to nursing workload, workflow processes, and patterns of communication with physicians and

other healthcare team members.[3]

Along these lines, Sensmeier emphasizes that “every organization needs nurses with competence in informatics so that EHR systems are
configured the right way, and are helpful and meaningful,” and that “chief nursing officers must advocate for what is needed to make these
systems right for nurses.”

How close are we to the solving the problems identified by nurses, and what does the future promise? Sensmeier responds, “We are making good
strides. In another 5 years, we will be in a really good place. We will see major improvements, and will be able to look at outcomes. Moreover, the
entire system will be less one-way — it will become more interactive. It will actually give information back to the nurse in the form of clinical
decision support. On the basis of intelligence (patient data entered by the nurse), the EHR will give the nurse evidence-based suggestions for
nursing interventions — a patient-specific, best-practice resource for the nurse to use.”

References

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Cite this article: Electronic Nursing Documentation: Charting New Territory. Medscape. Sep 12, 2013.

http://www.medscape.com/medline/abstract/20798619

http://www.medscape.com/medline/abstract/22024972