: The State of Things from a Nurse s Perspective Frances R. Eason, EdD, MSN, RN-BC, CNE, ANEF Professor, College of Nursing East Carolina University Greenville, NC Learning Objective: Describe the historical development, implementation and benefits of Electronic Health Records from a nurse s perspective.
CE On Your Own ARTICLE INVITED COMMENTARY Electronic Health Records: The State of Things from a Nurse s Perspective Frances R. Eason, EdD, MSN, RN-BC, CNE, ANEF Professor, College of Nursing, East Carolina University, Greenville, NC Introduction Recently, I was visited by a 6 year old in my office. To engage him in conversation, I asked him why he would need for his mom to write down the name of any medication that he used on a bug bite. After much discussion about the fact that no bug really bit him, we finally got back to the question. When asked again about getting mom to write down the date of the bite and the medication that they applied, I asked him why this was important. He loudly replied, so you will not forget you put Neosporin on it in case you see the doctor. Out of the mouths of babes! While being in this world just 6 years, he knew the most important purpose of documentation, and that is continuity of care. All nurses, irrespective of their work site or their title, no doubt are already using some form of electronic health records (EHRs). Or, their agency administration is considering the benefits, both from a fiscal as well as a human cost perspective, of implementing EHRs. As early as 2004, President Bush appointed a national coordinator for health information technology, Dr. David Brailer. During his tenure, Dr. Brailer proposed the switch from paper charts to the electronic format. Prior to this proposal, many companies had developed some template for EHRs and many agencies had already implemented some form of this technology, even if it were only the nursing assessment and nurses notes. Many supporters of EHRs are quick to point out the advantages of technology which include a long list of the reasons to implement. The actual implementation is very compelling when you consider the benefits of more efficiency and less time involvement by the health care team (Freudenheim, 2012). While EHRs cross all disciplines, the focus of this article is on nursing s approach to adopt, implement and evaluate EHRs. Good Old Days without Documentation or Were They? A look back in nursing assists us to appreciate how far we have come in the practice of documentation. In the beginning of nursing, the nurses role was mainly to care for the patient, the environment and the cooking, as well as other tasks that a person could not accomplish because of the illness. Since the nurse was on duty for long periods of time, including days or weeks, and the physician was the only other care provider, the nurse and physician could communicate verbally. Therefore, no day to day record was needed. Later, the process of maintaining a patient chart allowed nurses to have a specific time to work and the nurse was no longer required to reside at the hospital or the hospital owned nurses quarters, as had been the procedure in the early and mid-1800s. This was a major change as nurses were often required to sit up alternate nights and often only had a one day holiday in four weeks and each year, a one week s vacation (A Century of Nursing, 1950). When formal nursing was implemented in the late 1800s in the US, nurses had actual shift assignments, and the nurses were allowed to leave the agency after completing each assignment. These changes made it necessary to maintain a record of the patient events. These records went from just recording the unusual events to a time when each patient had a daily record. Later, in the 1950s and 60s, the process of documentation focused on activities of the shift, as the idea of a nurse completing an assessment was not yet being practiced. In fact, some of the first nursing assessment textbooks were made available in the 1970s and until that time, assessment was not even a word used in nursing. The activities of the shift were frequently documented by use of words such as; had a NCNA Convention, CE On Your Own F.R. Eason, 2013, 1 5 1
good day, in good spirits, no complaints, or complained all day of pain or walked in the hall. Documentation was mainly about the process and not how the activity affected the patient. This form of documentation required the nurse to at least make a summary statement at the end of the shift (end charts) and also to report the amount of the meal(s) the patient consumed. Meals were often recorded as ate well, took about ½ of the meal or some other quantity of food which was recorded as ate fair or ate poor. The other form of documentation that was used was block charting which was one comment at the end of the shift that summarized the activities of the shift. This form of documentation by the nurse was acceptable as there were no patient assessments, nor was there a focus by the nurse on patient outcomes. Nurses notes were often not reviewed by the next shift nurse or the physician, and most likely today we can appreciate that lack of review since the record was about activities and not patient outcomes. Was it really a patient record or truly a nurse s note? Records were maintained by nurses and as other disciplines became involved in the care, they too utilized the chart to record discipline focused assessment, patient progress and other information. Many agencies began to adopt formats such as PIE (Problem, Intervention, and Evaluation) or the SOAP (Subjective observations, Objective observations, Assessment, and Plan). Still this was done using a paper chart and handwriting. Also in use were nursing care plans that were based on the future, while the patient care record was primarily the past and the present. Often these care plans were discarded upon discharge and were considered work sheets and not part of the official record. As the years passed, different strategies were used in health care agencies to document in the patient record. Some of these strategies included charting by exception which may still be in use in some format today, and even serves as the basis for some templates of electronic records. While the idea of charting by exception seems very user friendly, the chart often times was an accumulation of the negative findings as a result of the patient assessment. Only the exceptions from normal were included and often times did not show improvements or the return to a normal state. Even as charting by exception became commonplace, Boards of Nursing continued with Nurse Practice Acts that indicated assessment results were to include all findings suggesting both the normal and the abnormal. Many agencies pre-printed forms that contained the expected normal as the criteria and the nurse checked the box if these normals were found. This saved a great deal of time; however nurses often complained that they felt as if they were not documenting enough. On the other hand, if deviations from the normal criteria were found, then the nurse would either highlight or place an asterisk in the normal box and write the exact exception to the normal. This format served nursing well if the guidelines for this type of documentation were taught and were followed by all of the nursing team. In addition, the handwritten paper format with contemporaneous or as it occurred observations is still in use today by many health care providers. So are flow sheets for both measurement and interventions that occur on a routine basis. Many of the early computerized clinical records that were used were based on flow sheet formats. Factors that Influenced Computerized Documentation In the late 1980s and the early 1990s, many areas of the US reported a nursing shortage. Quickly, many nurse advocates suggested that new methods were needed for supporting nurses, decreasing costs and maintaining effective health care while minimizing the effects of the nursing shortage. In addition, the storage of large volumes of patient records in paper copies was expensive and the accumulation was a major problem for many institutions. Scanning and storage on microfiche or other media was necessary, which was a labor intensive process. In addition, it was becoming common to read in nursing literature about errors made in health care and how computerized documentation could impact these errors especially those that were the direct result of handwriting. In particular, medication orders were often misread because of the handwriting and patients received medication too frequently or dosages not prescribed. At that time, the technology was available and being used in other fields which could impact these problems. For example, the technology was being used in supermarkets that mimic what we use today in health care to scan and determine correct medication dosage by use of a barcode. The timing was right for computerized documentation in health care and so many companies began to market the hardware and software to impact these needs. Nursing records seemed the appropriate place to start computerization since nurses documented a lot of data which was used by many other health care providers during the hospitalization of the patient. However, soon after discharge, this paper copy was usually filed and NCNA Convention, CE on Your Own F.R. Eason,2013,1 5 2
maintained at a cost for long periods of time, while basically being ignored. Only data used to report compliance with reporting requirements (Joint Commission) were actually used following discharge (Thede, 2008). One frequent question for health administrators is related to how EHRs would affect the profitability of the agency (Bresnick, 2013). All the while, the concerns voiced by nurses were different. A survey by AMN Healthcare reveals that on a scale of one to five, nurses aged 19 to 39 responded with an average score of 3.69 on questions about how EHRs positively influenced job satisfaction, the quality of patient care and productivity. Another finding of the survey indicated that nurses in older age groups, 40 to 54 or 55 and older, gave scores of 3.35 and 3.21 respectively on survey items related to job satisfaction, quality of patient care and productivity (Bresnick, 2012). Perhaps these scores with lower results in the older group were influenced by a limited past history of computer use and the familiarity of younger nurses with various electronic media. What is the State of EHRs in 2013? There is much written about EHRs today. While there are both cited advantages and disadvantages, one thing is for certain and that is health care probably will never return to a paper system for documentation. While the cost saving was projected by the RAND Corporation to be able to save the health care system at least $81 billion annually, this saving did not materialize over the period of 2005 to 2012. Cost saving was realized, but not nearly at the projected level. The more interesting finding is that the use of EHRs has increased the quality and efficiency of patient care, but only at a marginal level (Kliff, 2012). While others think that major cost savings are achievable in the future, the potential future may be changing in relation to what may occur. Therefore, savings are hard to predict. Another factor with the implementation of EHRs involves technical concerns but these are usually managed by a team of individuals with technical knowledge related to computer design. Hence, this adds to the cost of records generation as many agencies must add departments consisting of IT support personnel. Often, nurses may be added to the IT department for the first few years to support overall health record needs. However, more important issues for consideration today and in the future are those pertaining to professionalism and issues of an ethical nature. Agencies must generate policies related to security, abuse and protection of the record contents. Federal register mandates must be included in the policies and massive training of all personnel given access to the EHR must occur with frequent monitoring of compliance (Gaunt & Roger- France, 1996). Massive training of new personnel and training for existing personnel on keyboard skills if they do not already have these skills, as well as training for supervisory personnel as super users, must occur prior to the implementation or go live stage. As health care providers adapted to electronic records, the challenges have seemed daunting at times and the confusion about where to document and where to locate the correct forms was costly and slowed work production for nurses. On the other hand, many physicians complained that the EHR was more time-consuming and not provider friendly, and some even suggested they were not able to see as many patients as usual as they struggled with the screens and clicks. Likewise, nurses had similar concerns. (Freudenheim, 2012). Even with the satisfaction surveys and the improvements in productivity, nurses using EHRs continue to voice concerns and desires for new applications to resolve these concerns. Some of these concerns are interesting while others relate to safety issues. They include, but are not limited to: The ease of documenting a procedure with a click before the procedure is ever performed. The ease of relying on previous documentation and reporting these same findings. The difficulty in documenting the correct time a procedure is done, as opposed to the time you are documenting it (completed the procedure at 12 noon, but computer automatically records 1230, which was the documentation time). The difficult logistics with late entries. The lack of some systems to synchronize the lab results with the ability to administer a correct dosage of medication (if glucose levels could be automatically recorded on the Medication Administration Record, then insulin ordered on a sliding scale could be administered without the nurse having to transfer results). The EHR template may have 5 to 7 screens on a dressing whereas with paper charting, the nurse only charted, dressing dry and intact. While the results of the dressing assessment are more NCNA Convention, CE on Your Own F.R. Eason,2013,1 5 3
descriptive on multiple screens, much more time is involved in the documentation. The computer template may have a long alphabetical listing of the persons that could accompany a child to x-ray and mother is more than half way down the list which takes more time to scroll down to the box listing mother, than to document the letters, m-o-t-h-e-r. Many computer systems do not communicate with computer systems in other agencies. For example, a patient may be referred from a Community Health Clinic to a specialty agency and much copying or documentation has to be done to send with the patient to the second agency as the systems are not compatible. The continued concerns regarding breeches in patient information and linking patient data with other sources without the patient s knowledge (Layman, 2008). The need to have an agency watchdog to guard the EHRs to prevent breeches in the security systems. While nurses have often been an integral part of decision making regarding the system to purchase, it is usually after the system is implemented that events are often discovered that need attention and revisions. If there is a system in place to allow nurses to give feedback, and changes actually do occur in a timely fashion, the nurse feels empowered because their voice was heard. What is the future of EHRs? This is an interesting question. Today, the current EHR may only be a work in progress without an end date for perfection. New studies are emerging frequently in professional journals that provide additional information about EHR implementation and adoptions. The basic problems with these finding are that there are many different systems and so the findings cannot be generalized to all systems (Hagland, 2012). One thing is true and that is there may still be much untapped potential in the arena of EHRs which could impact safety, nurse satisfaction, more efficiency and an increase of patient satisfaction with the system. Nurses must be a part of this untapped potential with their ideas and dreams based on their experiences (Schwartz, 2012). Many users suggest it is time for the government to provide oversight into adverse events related to EHRs for the purpose of improving health care outcomes. This could be accomplished with mandatory reporting rather than with a system of voluntary reporting (Robertson, 2013). Perhaps as EHRs mature in their use, this will be accomplished. Only with nurse involvement in the selection, training and revisions of the EHRs will positive changes be made. The future could hold a deletion of patient records while documentation will be accomplished via video on a memory card. The recorder would be housed in every patient room. The nurse and other providers could then just verbally report vital signs and body sounds and these would be recorded on the video. There would be no question about how often the patient was assessed, when the patient was out of bed, or when they received medications, as it would all be recorded and stored in the memory card. Is this asking too much of the future when the technology is already there and waiting to be used? Maybe, as my 6 year old visitor walked out of my office with a toy that he referred to as a 3G, I should have asked him if there should be a camera to record what his mom did when the bug bite occurred, rather than have mom write it down. This would be done in case they did see a doctor. It is a thought. References Bresnick, J. (2012). Nurse involvement, acceptance is critical to successful EHR use. EHR Intelligence. http://ehrintelligence.com/2012/11/12/nurseinvolvement Bresnick, J. (2013). Is EHR mania hiding serious patient safety flaws? EHR Intelligence. Retrieved from http://ehrintelligence.com/2013/02/20/is-ehr- mania -hiding-. Freudenheim, M. (2012). The ups and downs of electronic medical records. The New York Times. http://www.nytimes.com/2012/10/09/health/theupsanddowns. Gaunt N. & Roger-France, F. (1996). Security of the electronic health care record professional and ethical implications. Stud Health Technol Inform. http://www.ncbi.nlm.nih.gov/pubmed/10163725. NCNA Convention, CE on Your Own F.R. Eason,2013,1 5 4
Hagland, M. (2012). Nurses know: EHRs improve patient safety. Healthcare Informatics. Retrieved from http://www.healthcareinformatics.come/blog/mark-hagland. Accessed on August 29, 2013. Kliff, S. (2013). Why electronic health records failed. Workblog. http://www.washingtonpost.com/blogs/wonkblog/w p/2013. Layman, E. (2008). Ethical issues and the electronic health record. Health care management. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18476119. National League of Nursing Education. (1950). A Century of Nursing. G.P. Putman s Sons, New York, N.Y. Robertson, J. (2013). Digital health records: Risks emerge as deaths blamed on systems. Bloomberg. http://www.bloomberg.com/news/2013-06- 25/digital - health-records-. Accessed on August 29, 2013. Thede, L. (2008). Informatics: The electronic health record: Will nursing be on board when the ship leaves? The Online Journal of Issues in Nursing. http://www.nursingworld.org/mainmenucatagories/ ANA Marketplace. Reflection Questions What is the most important purpose of documentation? What are advantages and disadvantages of nurses using EHRs? How have nurses made differences in the use of EHRs? Think of at least one example. What are concerns voiced by nurses as related to EHRs? What do you believe the future holds for EHRs as related to nursing practice? Overall, what benefit(s) do you believe you received from reading this article? NCNA Convention, CE on Your Own F.R. Eason,2013,1 5 5