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EHR Documentation

The Hype and the Hope for Improving Nursing Satisfaction and Quality Outcomes

O'Brien, Ann RN, MSN; Weaver, Charlotte RN, PhD, FAAN; Settergren, Theresa (Tess) MHA, MA, RN-BC; Hook, Mary L. PhD, RN-BC; Ivory, Catherine H. PhD, RN-BC

doi: 10.1097/NAQ.0000000000000132
Original Articles
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The phenomenon of “data rich, information poor” in today's electronic health records (EHRs) is too often the reality for nursing. This article proposes the redesign of nursing documentation to leverage EHR data and clinical intelligence tools to support evidence-based, personalized nursing care across the continuum. The principles consider the need to optimize nurses' documentation efficiency while contributing to knowledge generation. The nursing process must be supported by EHRs through integration of best care practices: seamless workflows that display the right tools, evidence-based content, and information at the right time for optimal clinical decision making. Design of EHR documentation must attain a balance that ensures the capture of nursing's impact on safety, quality, highly reliable care, patient engagement, and satisfaction, yet minimizes “death by data entry.” In 2014, a group of diverse informatics leaders from practice, academia, and the vendor community formed to address how best to transform electronic documentation to provide knowledge at the point of care and to deliver value to front line nurses and nurse leaders. As our health care system moves toward reimbursement on the basis of quality outcomes and prevention, the value of nursing data in this business proposition will become a key differentiator for health care organizations' economic success.

KPIT Care Delivery Business Information Office, & National Patient Care Services, Kaiser Permanente, Oakland, California (Ms O'Brien); Healthcare Executive and Nursing Informatics Pioneer, Atlanta, Georgia (Dr Weaver); Nursing Informatics, Enterprise Information Services, Cedars-Sinai Health System, Los Angeles, California (Ms Settergren); Department of Knowledge-Based Nursing (NBN), Aurora Health Care, Milwaukee, Wisconsin (Dr Hook); and Vanderbilt University School of Nursing, Nashville, Tennessee (Dr Ivory).

Correspondence: Ann O'Brien, RN, MSN, 5810 Owens Dr Bldg. F #2019, Pleasanton, CA 94588 (ann.o'brien@kp.org).

The authors acknowledge the extraordinary contributions of the Nursing Knowledge Big Data Science Workgroup 10 on Transforming Nursing Documentation.

The authors declare no conflict of interest.

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