Physician and Nurse Involvement Is Critical in EHR Selection and Implementation

Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies

I frequently hear some “older” physicians and nurses complaining about electronic health records (EHRs). They feel they inhibit documentation and are cumbersome and frustrating to use. However I can’t imagine any of the younger physicians or nurses would ever conceive of working in a system without electronic patient records.

As I was beginning to write this article, I began to wonder how many of you even remember the days in which there were no computerized records — when everything was in a written chart that was only accessible to one member of the healthcare team at any one time. I’m sure that must be more than half of you reading this article. For those of you that don’t know what it was like before computerized records, let me give you some insight.

Imagine having to submit a list of patients that you were going to see tomorrow in the clinic to the Medical Records Department (MRD) the day before so they could gather the records and bring them to the clinic that morning. Or if you are seeing a patient in the emergency department, you would need to call the MRD and ask them to bring the patient’s record to the ED. Until you get the record, you would be caring for the patient without having any medical history. And once you are finished with the record, it would need to be returned to the MRD for filing or, if the patient was admitted, the record would need to be transferred to the floor with the patient. 

If the patient had any lab, X-ray, or other procedures done within the last day or so, those results would probably not be filed in the record yet. They would still be with the provider for review or waiting to be filed. In the hospital, if these results were needed right away, they would be sent to the department via an archaic pneumatic tube system that was available throughout the facility. (And they often got sent to the wrong area!) In addition, only one person had access to the patient’s record at a time. Other care team members could not review the record to help them make clinical decisions.

Is that system archaic enough to convince you that we need electronic medical records? If not, let’s talk about how the record was documented. All notes were written manually (and hopefully they were legible enough so everyone could interpret them). There was no automated documentation or structured documentation standards that make it easier to find information. There was also no automated medication information, lists, or order entry, nor any decision support tools. These were only available in reference books that might not be readily available when you needed them.

Okay! Have I convinced you yet that the minor inconveniences that we may have in using an EHR today is better than using written records? I hope so. Are there things we can do to make the EHR system perform better and meet our needs? Absolutely! But we need to get involved!

I’d like to share with you portions of a blog written by Debb Keller, RN, the CEO of TCS Healthcare Technologies. Debb feels that it is critical for physicians and nurses to be intimately involved in the selection and implementation of EHRs in order to make them work efficiently. Here are portions of Debb’s blog, Why Practitioners, and Nurses Especially, Need to Be More Involved With EHRs.

“Electronic Health Records - EHRs. In theory, it sounds so simple. I mean, who keeps paper records anymore? Open a bank account or a credit card, and they’ll encourage you to “go paperless” and receive bills and statements only electronically. Cloud storage services allow you to store all your files in a way that allows you to access them anywhere. Address books are replaced with contact lists, and now you even have the option of receiving an e-receipt instead of a paper one when you buy a cup of coffee.

“Why, then, do EHRs live in infamy in the healthcare world? It’s not because electronic records aren’t useful in healthcare: they allow access to information at the point of care, and they help avoid problems like misreading or mishearing written or phone prescriptions, which can lead to a patient receiving the wrong medication.

“The issue at hand is the user-friendliness of these technologies. ……. A whopping 44% of physicians and 35% of Nurses and APRNs (Advance Practice RNs) surveyed in a Medscape poll said that EHRs had reduced the quality of care they were able to provide. Those surveyed cited problems such as ‘added paperwork/charting, entering data during the patient encounter, lack of interoperability with other systems and system failures or problems.’  

“These technological pain points have not only reduced care quality in the eyes of large proportions of practitioners, they also reduce job satisfaction, which contributes to burnout.

“Although there isn’t a silver bullet to improve such a complex problem, the first step is to increase the involvement of practitioners with EHRs. No matter where your healthcare practice or company currently stands with its EHR system, there are actions to be taken:

“1)   EHR system currently in use: even if you have an EHR system and aren’t in a position to replace it, you can still take steps to improve things for your healthcare professionals and, in turn, your patients. It shouldn’t come as a surprise that educating on a subject makes it more manageable, but in a study by Arch Collaborative, tens of thousands of clinicians were interviewed and found to have ‘critical gaps in users' understanding of how to optimize their EHR.’ Though no amount of training can fix flawed technology, it can certainly improve both experience and outcomes.

“2)   Implementing an EHR system: there are a lot of EHR systems on the market, and choosing the right one isn’t always easy. The choice will certainly vary based on your practice. Now, who do you think will have the best sense of the needs of your practitioners? I think you know where this one is going. 66% of physicians and 80% of APRNs/nurses were not consulted in the EHR system selection process, according to a Medscape poll, and of those who did weigh in, only 2% said the system they wanted was chosen. Now, I can understand that sometimes, the opinions of practitioners might not be what the practice goes with in the end; it could come down to a budget or system compatibility issue. However, the fact that it’s so infrequent, among companies who are bothering to ask at all, can’t be chalked up to those excuses.

“3)   Companies designing EHRs: for technology companies in the healthcare space, just like any other, user experience design is so important. Whatever approach you may take, whether it is having clinicians work directly with the design team, doing extensive user research, or undergoing extensive user testing, bringing in end users is going to give you a product that works better for them. For instance, Dr.  Lalita Abhyankar wrote in an OpEd entitled “You Hate Your EHR? Help Develop Something Better” about her experience going to a meetup for people interested in healthcare tech. ‘As I walked home in the cold that night, I realized, perhaps, the reason we are the victims of poorly designed technology is because many of us haven't yet elbowed our way to a seat at the table.’ Challenging though it may be, we can all try to get to the table and give our opinions.

“I want to note that while it’s important for every end-user to be involved in development, selection, and implementation of EHRs, involving nurses and APRNs is especially important. Although studies have shown that overall, nurses are more satisfied with their EHRs than physicians, they still face a lot of issues using them, and over one third still feel they were reducing care quality. Moreover, ‘The majority of the care-delivery support that occurs in the EHR is completed by nurses.’

“Patricia Daly puts it especially well in an article for LWW’s Nursing Journal: ‘These clinical nurses are experts in patient-care delivery and can articulate the needs of patients, families, and nurses to HIT professionals.’

“Every single day ……., I draw on my experience as an RN. As a practicing nurse, the resources I needed were provided by technology companies. As the CEO of a technology company, the resources I need are provided by clinicians—their knowledge and expertise is essential to me and my team doing our jobs as effectively as possible.

“I believe so strongly that technology in the healthcare space (including EHR) is just getting started. It has the enormous capacity to not only help practitioners by making their lives easier but help them help patients as well. And that’s the ultimate goal here, isn’t it? Helping patients!”

Very well said, Debb.  I think it is clear that we all need to “elbow our way to the table” and get involved.  Sure, EHRs can be frustrating at times, but not as frustrating as returning to an archaic written record. I don’t think anyone can deny that EHRs increase the quality of patient care and the efficiency of the staff. However, we can even make these systems better by providing input into their selection and implementation. Next month, we will look at what we can do to help select the right EHR and how to make sure the system is implemented in a way that meets our needs and those of our patients.  

Pat Stricker, RN, MEd, is senior vice president of Clinical Services at TCS Healthcare Technologies. She can be reached at pstricker@tcshealthcare.com.