In this high-tech era, the use of computerized health records, commonly referred to as electronic health records (EHRs), or electronic medical records, is now ubiquitous. The migration to EHR systems, however, has not been smooth; it has tested the assumption that these systems would easily and seamlessly achieve the goal of making health care safer and more efficient.
Despite many success stories, there has been significant pushback and dissatisfaction from the health care workers who use EHRs. “The vast majority of hospitals, clinics, and other health care settings have implemented EHRs,” said Linda Harrington, PhD, DNP, RN-BC, CNS, an independent consultant and professor of health informatics and digital strategy at Baylor College of Medicine in Houston. “Now we are seeing increasing and often conflicting nursing research on their benefits and challenges.”
THE EVOLUTION OF EHRS
While EHRs have gotten a lot of attention in recent years, the concept of maintaining medical records on computer goes back decades. Early efforts by academic medical centers to develop their own systems began in the 1960s and 1970s. The Institute of Medicine (IOM, now the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine) studied the use of paper health records in the 1980s and 1990s and advocated EHR use as a way to improve accessibility and accuracy of patient records.
A major push for EHRs came in 2001, when the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century, which called for a national commitment to building an information infrastructure that “should lead to the elimination of most handwritten clinical data by the end of the decade.” Two years later, another IOM report, Key Capabilities of an Electronic Health Record System, identified eight core functions that EHR systems should be able to perform in order to positively impact safety, quality, and efficiency—among them, patient support, decision support, and administrative processes and reporting.
In 2011, the Centers for Medicare and Medicaid Services (CMS) launched a multiyear, multiphase incentive program to increase both physician and facility use of EHRs. The program offers payment to encourage the use of EHR technology in “meaningful” ways, such as electronic prescribing, implementing drug–drug and drug–allergy interaction checks, and communicating with patients online. As of July 2016, the CMS reported that more than 506,000 health care providers have received payment for participating in the Medicare and Medicaid Electronic Health Record Incentive Programs, and more than $23.7 billion in Medicare incentive payments have been made between May 2011 and July 2016.
“Physicians have been very vocal about [their issues with EHR systems],” said Nancy Staggers, PhD, RN, FAAN, professor of informatics and biomedical informatics research at the University of Utah in Salt Lake City. “But nurses also have issues with many of the current platforms.” To start, EHR platforms aren't designed to fit the way nurses work. “Almost every nurse takes care of a group of patients,” said Staggers, “and EHRs are designed [to focus on] a single patient.”
Data entry. EHRs’ focus on physician or NP orders is another fundamental issue, said Staggers. “Orders do not represent nurses’ work—they are just a small part of it—and EHR platforms are generally not set up for all of the planning and priority setting, and everything else that nurses do.”
Additionally, EHR systems don't always account for the many steps, variables, and people involved in nursing practice, according to Staggers. “If a nurse has a question, or a dose is missed for some reason, there is no place to enter that [in the EHR].” It might be possible to attach a “sticky note” to the medication record, but communicating that way is cumbersome. And such a note “can be easily missed, because it is unreasonable to expect that a nurse is going to open every single note,” Staggers pointed out. Another nursing complaint is the amount of time documentation can take: some nurses have reported that conducting assessments using EHR systems can take an hour or more.
Ease of use. EHR platforms also have inherent problems with usability, a term that, according to Harrington, refers to “the ease of use and usefulness of EHRs to nurses in their practice.” Challenges to EHR usability include workflow issues, forced word choices, lack of or limited free text, and difficulty finding data or information, among others.
Harrington said the largest drawback of EHR use for nurses is the lack of sufficient benefit for the amount of time and energy invested. She notes that EHR systems have “yet to achieve electronic documentation to any significant degree.” What has been achieved thus far is the ability to transfer the task of data entry from a paper platform to an electronic platform, but the actual work of documentation is still largely manual.
Patient safety. Even though EHR systems have added mechanisms for improving patient safety, such as alerts and barcode use in medication administration, new safety issues have arisen. These issues are often created by “workarounds used by nurses to address usability issues,” said Harrington. For example, a nurse may “borrow” an urgently needed drug for a patient before a physician has entered the order in the EHR. Or she or he might “copy and paste” a patient's previous assessment in the EHR instead of doing a time-consuming new one.
A 2014 survey of RNs by Black Book Market Research—which polled nearly 14,000 RNs working in 40 states, all of whom had used hospital EHRs during the last six months—offered insight into the frustrations nurses experience when using EHRs and yielded an unsettling finding: 67% of respondents reported that they had been taught workarounds to allow other members of the team to view pertinent patient information, so as to prevent any negative impact on the quality of care and avoid unresolved flaws in the EHR system.
Communication. A large majority (90%) of Black Book survey respondents said that EHR use had negatively impacted communication between nurses and patients. Most (94%) also didn't think that the EHR currently used in their facility had improved communication between nurses and the rest of the health care team. Only about a quarter (26%) agreed with the statement, “As a nurse, I believe the current EHR at my organization improves the quality of patient information.”
Tech support. Just 30% of nurses polled in the Black Book survey said they believed that their institution's administration and information technology (IT) department responded quickly to making changes to the EHR in response to vulnerabilities in documentation recognized by nurses. Among nurses working in for-profit inpatient settings, more than double that percentage (69%) said the opposite: in working with the EHR software, their IT department was “incompetent.”
LOOKING TO THE FUTURE
Given the many issues that currently plague the use of EHRs, what improvements can health care providers hope to see as the platforms evolve? “The promise of EHRs involves their basic function as a database [that] will eventually be part of a larger database system,” Harrington said. “The problems associated with entering data into EHRs for documentation will fade in the next few years as increasing amounts of data are automatically populated via medical device integration, sensors, imaging, voice recognition, and so on, rather than with manual entry.”
She added: “The key for now is having a good EHR safety program in place, plus prioritizing usability while moving documentation to automated processes. The result will be an EHR that moves from data taking to information giving, augmenting clinical decision making for better individualized prevention, early intervention, and care.”—Roxanne Nelson