EMRs for RN's
(This is an academic paper, APA format, though much of the format is lost in the blogger interface)
When significantly new technologies are introduced into a highly structured workflow like professional nursing, there can be negative reactions from the staff. Knowledge and education are the tools that are used to combat that negativity and help lessen the fear. Patient safety is paramount to all healthcare providers and facilities. However, that safety is often compromised through various avenues, including the most basic: written documentation (the “chart”). Electronic documentation is one tool that can help health care practitioners provide safer care, if the nurse who is using the application does so in the correct manner, with minimal workarounds. This is more likely to happen if the nurse understands the “why” behind the mandates. The focus of this paper is to educate nurses (RNs and LPNs) who work in the inpatient setting on why electronic documentation is becoming part of the workflow, how that workflow will change, and some of benefits and drawbacks associated with the use of electronic documentation.
• Decreased adverse drug events
• Overall improved patient safety
• Decreased patient complaints and financial outlay (malpractice)
• Reduced number of a patient leaving the emergency room (ER) without being seen.
• Reduced pharmacy costs
• Reduced paper costs
• Reduced filing and storage costs reduced overtime costs
• Reduced LOS
• Reduced days in accounts receivable (AR) due to lower denials
• Increased nurse retention
• Increase in revenue from the ER
• Triage is quicker
• Patient confidentiality is protected by the ability to silently review prior data
• Increased compliance with Joint Commission and National Patient Safety Guidelines
• Patients are not asked to fill out forms requesting the same information time after time, increasing patient satisfaction.
• Essential information available at the point of care
• Facilitates rapid analysis and communication for questionable care aspects, such as a medication order
• Standardized data collection makes it easier to defend against
• Quality assurance can be validated with hard data
These results are not a onetime, singular event. A study by Bhattacherjee, Hikmet, Menachemi, Kayham, and Brooks (2007), indicated that these positive results tend to fall into three categories: the clinical cluster, the administrative cluster, and the strategic cluster. They found electronic documentation --a part of the total healthcare information technology (HIT) package—had the greatest impact on the clinical cluster, while the administrative and strategic cluster received a positive, though not significant correlation. Robles (2009, p.32) indicates that other benefits include “improved billing accuracy, improved interdisciplinary communication resulting in improved continuity of care, evidence-based decision support, improved documentation, enhanced legibility, reduced duplication and improved speed with which orders are implemented.”
• Nurse discomfiture at documenting at the bedside
• Workarounds that may have significant consequences
• Once fully implemented, some nurses need to be reminded that the application is a tool and not a substitute for nursing training and clinical judgment.
• Reverting to downtime procedures that may be rusty or unknown to newer staff
• Current lack of system, regional and national interoperability
• Because electronic documentation systems capture data and have a reporting capability, some nurses fear a punitive environment
• Culture change
• Fear about the safety of patient information
• Clumsy and inadequately designed application interfaces--cumbersome
• No in-place policy for the new E-discovery law time tables and the interplay that has with the health insurance portability and accountability act (HIPAA)
• Possible multiple applications to access if patients move from one level of care to another
• Problems with the technical and wireless infrastructure:
o Dead zones
o Unreliable servers that can overload and go down
• Potential legal implications if a nurse has to double or triple document and the information does not match
• Dead zones or unknown issues can induce a nurse to give medications that have not been properly scanned, bypassing safety measures.
• System errors can mean garbled or no information to retrieve.
• Risk management fear of the senior leadership rushing to purchase any system, to be in compliance
• Possible product incompatibility, rendering any interoperability a null point
• Cannot locate a mobile workstation
• No power or dead batteries in mobile workstations
• Difficult to maneuver mobile computer into a semi-private room
• Nurse fear of violating the HIPAA law in a semi-private room during an assessment
• Cost
Although there seem to be many more drawbacks than benefits, the types of issues seem to fall within one of two camps, hard and soft. The hard issues, the infrastructure, legal and technical drawbacks are not so easily conquered. The majority, however, is related to training and coaching and can be overcome.
Training and Coaching for Implementation Success
Communication is key to a successful rollout. If at all possible, communication to the staff, including product information and demonstrations should take place as soon as feasible. Training schedules need to conform as much as possible to the nurses’ schedules, i.e., day classes for day shift, night classes for nights.
3. Senior leadership is firmly on board with the training and short term need for additional staff to cover those shifts.
4. Use of positive reinforcement.
5. Remind everyone that this is just a different way to record information.
6. Champions are chosen to facilitate the roll-out, including physicians.
7. The product chosen would be easily integrated into the workflow. If it is not, senior hospital and information technology (IT) leadership, along with floor nurses need to meet to make it at close as possible.
8. Training is held in convenient locations, during multiple time frames.
9. Super-users are actively recruited and used during training
10. After training, a practice unit is available to work with.
11. Policies are updated and nurses are required to sign off on those.
12. Establish a command post staffed with nursing leadership, systems analysts and clinical informatics.
13. Support staff, ideally clinical staff that works in IT, to be available during the go-live process around the clock to help users and for a period afterward.
14. Be positive and supportive, especially of older learners.
Conclusion
Hospitals do not need to make the decision to go to electronic documentation; it is a law that demands compliance by 2014. The decisions to be made lie in the realms of what product to purchase, how to notify the staff, what assessments to accomplish, training and support to develop and oversee. Next to the purchase itself, nothing is more important than the education and training of the front line nurses who will be using the applications to provide care to any number of patients in an increasingly chaotic environment, with more and more being asked of the floor nurses who form the backbone of any institution.
References
© 2009 Ruth Molenaar
Abstract
When significantly new technologies are introduced into a highly structured workflow like professional nursing, there can be negative reactions from the staff. Knowledge and education are the tools that are used to combat that negativity and help lessen the fear. Patient safety is paramount to all healthcare providers and facilities. However, that safety is often compromised through various avenues, including the most basic: written documentation (the “chart”). Electronic documentation is one tool that can help health care practitioners provide safer care, if the nurse who is using the application does so in the correct manner, with minimal workarounds. This is more likely to happen if the nurse understands the “why” behind the mandates. The focus of this paper is to educate nurses (RNs and LPNs) who work in the inpatient setting on why electronic documentation is becoming part of the workflow, how that workflow will change, and some of benefits and drawbacks associated with the use of electronic documentation.
The Issue
When significantly new technologies are introduced into a highly structured workflow like professional nursing, there can be negative reactions from the staff. Often the fear of the unknown, especially in terms of how a technology might affect job function and the future, can create a negative work atmosphere and a resistance to learning and utilizing the technology. Knowledge and education are the tools that are used to combat that negativity and place the technology in the light it is meant to be used in: as a means to help the professional achieve set goals.
All nursing professionals are taught correct documentation formats and requirements and the maxim: if it is not documented, it is not done. However, often there is little time to complete a chart in the prescribed manner and the result is documentation is often sketchy, illegible, missing information or incorrect. This can lead to several types of medical errors, with consequences ranging from negligible to the inadvertent death of the patient. It also opens the nurse to legal implications. Nursing documentation rules are always changing and evolving. There are abbreviations that change, that are legal one year and not the next, and the rules of documentation more and more often being driven by legislators and payers that patient needs. Nurses are constantly reminded that the chart is a legal document. They often need to be reminded as well, that the chart is a communication tool between every member of the care team (Brown, 2008).
Legally speaking, the context of the chart, the verbiage, completeness, use of unapproved abbreviations, neatness, or lack thereof, are often the first impression the court has of a nurse. It is difficult to prove one is a conscientious nurse if the documentation cannot support that. Incomplete charting, even by top tier nurses, is seen as negligence, and poorly worded nursing notes can be seen as a self-admission of inappropriate treatment. Since an estimated 15 to 20 percent of a nurse’s day is spent in documentation, he or she has many opportunities to get something wrong (Brown, 2008).
A Solution
According to the U.S. Institute of Medicine, there are over 97,000 medication-related deaths each year in the united stated. They also indicate that these mistakes could be avoided with electronic patient documentation at the point-of-care (Abraham, Watson & Boudreau, 2008). The authors also point out that most nurses are more likely to be acceptant of the new technology if they know how the technology works and the benefits derived from it
The electronic health record (EHR), variously called the electronic medical record (EMR) and the electronic patient record (EPR) among others, is a way to have standardized charting, capturing the legal and financial needs and the patient care notes all the health care team needs to provide care (Abraham, Watson & Boudreau, 2008, Robles, 2009)
Electronic documentation of health information implementation, i.e. the implementation of electronic medical records (EMRs), was mandated by the former President George W. Bush. The 2004 mandate requires that by the year 2013, all medical records will be kept electronically (Baker, 2008, Thielst, 2007). More recently, the 2009 stimulus package finalizing its way through Congress has a provision to award up to 11 million dollars per hospital system that can prove a significant use of electronic medical records (Manos, 2009). These are just a few of the many driving forces behind the implementation of EMRs that may not be communicated to the floor level nurse, who only sees yet another task to add to his or her already overtaxed day.
Electronic documentation is one tool that can help health care practitioners provide safer care, reduce expenditures, and after the initial learning curve, save time with most applications, providing the nurse who is using the application does so in the correct manner, with minimal workarounds. This is more likely to happen if the nurse understands the “why” behind the mandates (Robles, 2009).
Benefits of the EMR
Patient safety is the most oft-cited reason for implementing a healthcare information system (HIS). The reduction in medication errors alone would make any healthcare information technology (HIT) worth the cost. An application such as McKesson’s Admin RX program can validate the medication order with the pharmacist before the medication is labeled, dispensed, scanned and administered. It can prevent a nurse from inadvertently violating one of the five rights of medication administration: right drug, right dose, right time, right route, right patient, by giving the nurse alerts based on these parameters and the patients information that includes allergies and weight (for titrated drugs) (Koppel, Wetterneck, Telles & Karsh, 2008).
One of the benefits of using an EMR is that eventually entire health records will be able to be called up at any office or hospital, reducing duplicate tests, contraindicated prescriptions and tests, which can, in turn, result in a shortened length of stay (LOS) that in turn lowers costs for the hospital, insurance payers and the patient (Taylor, 2008).
One health system that went completely electronic in 2005 has realized substantial benefits operationally, financially and clinically. Banner Health’s newest hospital, Estrella Medical Center (EMC) in Arizona was designed to be electronic from the ground up. EMC saved 2.6 million in just over three years. Beaty (2007), Brown, (2008), Hensing, et al, (2008), and Robles (2007) offer some of the benefits realized by EMR:
• Decreased adverse drug events
• Overall improved patient safety
• Decreased patient complaints and financial outlay (malpractice)
• Reduced number of a patient leaving the emergency room (ER) without being seen.
• Reduced pharmacy costs
• Reduced paper costs
• Reduced filing and storage costs reduced overtime costs
• Reduced LOS
• Reduced days in accounts receivable (AR) due to lower denials
• Increased nurse retention
• Increase in revenue from the ER
• Triage is quicker
• Patient confidentiality is protected by the ability to silently review prior data
• Increased compliance with Joint Commission and National Patient Safety Guidelines
• Patients are not asked to fill out forms requesting the same information time after time, increasing patient satisfaction.
• Essential information available at the point of care
• Facilitates rapid analysis and communication for questionable care aspects, such as a medication order
• Standardized data collection makes it easier to defend against
• Quality assurance can be validated with hard data
These results are not a onetime, singular event. A study by Bhattacherjee, Hikmet, Menachemi, Kayham, and Brooks (2007), indicated that these positive results tend to fall into three categories: the clinical cluster, the administrative cluster, and the strategic cluster. They found electronic documentation --a part of the total healthcare information technology (HIT) package—had the greatest impact on the clinical cluster, while the administrative and strategic cluster received a positive, though not significant correlation. Robles (2009, p.32) indicates that other benefits include “improved billing accuracy, improved interdisciplinary communication resulting in improved continuity of care, evidence-based decision support, improved documentation, enhanced legibility, reduced duplication and improved speed with which orders are implemented.”
Known and Potential Problems
However, the greatest advances will not achieve its’ potential if it is not utilized properly. It is important to realize, for patients, nurses and administrators alike, that electronic documentation, or even a full HIS system, is not a universal remedy for every problem, and in fact, any problems with a process are often magnified when it is computerized (Robles, 2009).
Some patients, the families of those patients, and even some nurses, especially those of the older generation, complain that the nurses spend more time with machines than they do with the patients. This can be true and is often dictated by the level of experience a nurse has with computer equipment and the ease with which he or she can navigate the application (Robles, 2009).
In fact, it has been shown in Alquraini, Alhashem, Shah and Chowdhury’s 2007 examination of nurses and computer use that the younger generation of nurses, in general, are more comfortable using computers and much more at ease learning new applications that their older counterparts. That being said, they did find that as a group, nurses are resistant to the computerization of healthcare, citing that it is dehumanizing and unfeeling. This helps to explain why so many nurses have such a hard time adapting to the electronic record; to them, it appears that the implementation of such applications is in direct conflict of their life work
Some of the problems, both known and perceived, that are a part of a HIS implementation, even one that incorporates nothing more than the electronic record are multiple, and often related to misconceptions, fear, training issues, and resistance to change. Once those deficits are remedied there are still a goodly amount of drawbacks. Multiple researchers and authors (Alquraini, Alhashem, Shah, & Chowdhury, 2007, Beaty, 2007, Bhattacherjee et al. 2007, Hensing, et al. 2008, Joch, 2008, Moody, 2004, Robles, 2009) have cited the following:
• The time it takes to learn a new application
• Overtime while in the learning curve
• Connectivity problems
• Slowed work routines• Connectivity problems
• Patient preference for face to face contact
• Nurse preference for face to face contact• Nurse discomfiture at documenting at the bedside
• Workarounds that may have significant consequences
• Once fully implemented, some nurses need to be reminded that the application is a tool and not a substitute for nursing training and clinical judgment.
• Reverting to downtime procedures that may be rusty or unknown to newer staff
• Current lack of system, regional and national interoperability
• Because electronic documentation systems capture data and have a reporting capability, some nurses fear a punitive environment
• Culture change
• Fear about the safety of patient information
• Clumsy and inadequately designed application interfaces--cumbersome
• No in-place policy for the new E-discovery law time tables and the interplay that has with the health insurance portability and accountability act (HIPAA)
• Possible multiple applications to access if patients move from one level of care to another
• Problems with the technical and wireless infrastructure:
o Dead zones
o Unreliable servers that can overload and go down
• Potential legal implications if a nurse has to double or triple document and the information does not match
• Dead zones or unknown issues can induce a nurse to give medications that have not been properly scanned, bypassing safety measures.
• System errors can mean garbled or no information to retrieve.
• Risk management fear of the senior leadership rushing to purchase any system, to be in compliance
• Possible product incompatibility, rendering any interoperability a null point
• Cannot locate a mobile workstation
• No power or dead batteries in mobile workstations
• Difficult to maneuver mobile computer into a semi-private room
• Nurse fear of violating the HIPAA law in a semi-private room during an assessment
• Cost
Although there seem to be many more drawbacks than benefits, the types of issues seem to fall within one of two camps, hard and soft. The hard issues, the infrastructure, legal and technical drawbacks are not so easily conquered. The majority, however, is related to training and coaching and can be overcome.
Training and Coaching for Implementation Success
Communication is key to a successful rollout. If at all possible, communication to the staff, including product information and demonstrations should take place as soon as feasible. Training schedules need to conform as much as possible to the nurses’ schedules, i.e., day classes for day shift, night classes for nights.
Outline for Success: (Abraham, Watson, & Boudreau, 2008, Beaty, 2007, Joch, 2008):
1. Computer literacy training for all staff before the rollout of the product.
2. Go slow.3. Senior leadership is firmly on board with the training and short term need for additional staff to cover those shifts.
4. Use of positive reinforcement.
5. Remind everyone that this is just a different way to record information.
6. Champions are chosen to facilitate the roll-out, including physicians.
7. The product chosen would be easily integrated into the workflow. If it is not, senior hospital and information technology (IT) leadership, along with floor nurses need to meet to make it at close as possible.
8. Training is held in convenient locations, during multiple time frames.
9. Super-users are actively recruited and used during training
10. After training, a practice unit is available to work with.
11. Policies are updated and nurses are required to sign off on those.
12. Establish a command post staffed with nursing leadership, systems analysts and clinical informatics.
13. Support staff, ideally clinical staff that works in IT, to be available during the go-live process around the clock to help users and for a period afterward.
14. Be positive and supportive, especially of older learners.
Conclusion
Hospitals do not need to make the decision to go to electronic documentation; it is a law that demands compliance by 2014. The decisions to be made lie in the realms of what product to purchase, how to notify the staff, what assessments to accomplish, training and support to develop and oversee. Next to the purchase itself, nothing is more important than the education and training of the front line nurses who will be using the applications to provide care to any number of patients in an increasingly chaotic environment, with more and more being asked of the floor nurses who form the backbone of any institution.
Electronic documentation has both benefits and drawbacks, however, the choice to use EMR or not has been take from the individual nurse, as is the choice of which product he or she will be expected to learn. Nurses need to remember they are professionals, and that change is a part of every nurse’s vocabulary and work life. Procedures change, roles and standards change as time goes by. EMR is just another change that the nurse can and will master. By seeing that, learning the system and continuing to grow, EMR will be seen as significant, but no more troublesome than losing the cap by future nurses.
References
Abraham, C., Watson, R., & Bcudreau, M. (2008, June). Ubiquitous Access: On the Front Lines of Patient Care and Safety. Communications of the ACM, 51(6), 95-99. Retrieved January 18, 2009, from Business Source Complete database.
Alquraini, H., Alhashem, A., Shah, M., & Chowdhury, R. (2007). Factors influencing nurses’ attitudes towards the use of computerized health information systems in Kuwaiti hospitals. Journal of Advanced Nursing, 57(4), 375-381. Retrieved January 18, 2009, doi:10.1111/j.1365-2648.2007.04113.x
Baker, Pam. (Dec 6, 2008). Medical Technology Journal - 2008 - The Year in Review. Retrieved January25, 2009, from http://www.medtechjournal.net/content/view/298/10059/.
Beach T. C. (2007, January). The Future of Healthcare Technology. Journal of Healthcare Management, 52(1), 7-9. Retrieved January 18, 2009, from Academic Search Premier database.
Beaty, B. (2007). The Electronic Medical Record: Shifting the Paradigm. Creative Nursing, 13(2), 7-9. Retrieved March 3, 2009, from Academic Search Premier database.
Bhattacherjee, A., Hikmet, N., Menachemi, N., Kayhan, V., & Brooks, R. (2007, Winter2007). The Differential Performance Effects of Healthcare Information Technology Adoption. Information Systems Management, 24(1), 5-14. Retrieved March 3, 2009, doi:10.1080/10580530601036778
Brown, A., & King, D. (2008, March). The science of documentation. Dean's Notes, 29(4), 1-3. Retrieved January 17, 2009, from CINAHL with Full Text database.
Hensing, J., Dahlen, D., Warden, M., Van Norman, J., Wilson, B., & Kisiel, S. (2008, February). Measuring the benefits of IT-enabled care transformation. Healthcare Financial Management, 62(2), 74-80. Retrieved January 18, 2009, from Business Source Complete database.
Joch, A. (2008, February). IT at a crossroads. H&HN: Hospitals & Health Networks, 82(2), 45. Retrieved January 18, 2009, from CINAHL with Full Text database.
Koppel, R., Wetterneck, T., Telles, J., and Karsh, B. (July/August 2008). Workarounds to barcode administration systems: their occurrences, causes, and threats to patient safety. Journal of the American Informatics Association 15(4) 408-423.
Manos, D. (Feb 12, 2009). Healthcare IT slated for $19B in proposed stimulus package in Industry News: Healthcare IT News. Retrieved February 12, 2009 from http://www.healthcareitnews.com/news/healthcare-it-slated-19b-proposed-stimulus-package.
Robles, J. (2009, January). The Effect of the Electronic Medical Record on Nurses' Work. Creative Nursing, 15(1), 31-35. Retrieved March 3, 2009, doi:10.1891/1078-4535.15.1.31
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