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59 clicks in the EHR

Kroning, Maureen EdD, MSN, RN

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doi: 10.1097/01.NURSE.0000526893.25553.37
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WHEN PERFORMING rounds as a nursing supervisor at the acute care hospital, I heard a nurse complain that it took 59 clicks on the electronic health record (EHR) to update her patient's plan of care. This complaint led me to conduct a literature review on the problems associated with electronic documentation as well as informally speak to nurses at the hospital about the EHR challenges and benefits they encounter. This article discusses what I found, including the benefits of EHRs and the elements of EHRs that need further improvement.

Current state of practice

The Office of the National Coordinator (ONC) for Health Information Technology, a branch of the Department of Health and Human Services, was established in 2004 to manage and provide standards for the government's stimulus program. According to ECRI Institute, “with funding appropriated by the Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government is spending about $19 billion to encourage hospitals, physician practices, and other healthcare organizations to invest in their health IT infrastructure.” The ECRI Institute states that most incentive money will be given to healthcare organizations after they demonstrate effective use of EHRs.1

EHRs have benefits for both nurses and patients. According to, the many advantages to EHRs include providing up-to-date patient information, quick access to patient records, increased coordination and efficiency of patient diagnosis and patient care, prevention of medical errors, improved patient-provider communication, more reliable prescribing, streamlined coding and billing, and improved productivity and efficiency while decreasing healthcare costs. As a result of the HITECH Act, the nursing profession has had to learn, adjust, and change the way it's been providing patient care.2

On February 17, 2009, the HITECH Act was signed into law.2 The Act was designed to promote the adoption and meaningful use of health information technology by providing healthcare organizations with incentives for using EHRs to exchange patient clinical data among healthcare providers, insurers, and patients.2 The Medicare and Medicaid EHR Incentive Programs provide eligible professionals up to $44,000 through Medicare incentives and up to $63,750 through Medicaid incentives, with hospital incentives of $2 million or more.3

According to the ONC for Health Information Technology, three hospitals of every four in the United States have an EHR system in place.4 Both Centers for Medicare and Medicaid Services and ONC require that professionals and hospitals use EHR systems that are certified by the incentive program. They also require adherence to standards and criteria in order to be eligible for the incentives.5 The ONC for Health Information Technology reported that as of June 2016, of 4,474 U.S. nonfederal acute care hospitals in the Medicare EHR Incentive Program, 95% had the 2014 certified edition technology in place.2,5

Legislation about EHRs has directly impacted nursing practice. When Farzad Mostashari, the former CEO of the ONC for Health Information Technology, was asked about EHR shortcomings, he noted that considering how much time is spent on data entry, the data should be more usable.6

He was echoing a common complaint of many nurses. Those I've spoken with at the local hospital say that the many access points for inputting data create duplicate entries. The nurses believe that they should have had a more active role in implementing EHRs in clinical nursing practice to make it more efficient for them to use. Healthcare professionals working at the bedside can't choose whether or not to use the EHR. Healthcare administrators need to be aware of what those providing care and documenting it in the EHR consider to be its advantages and disadvantages.

Facing the challenges

EHRs haven't been easy to incorporate into practice. Many nurses at the local hospital reported challenges when using EHRs that were similar to those revealed by research. A qualitative research study of six primary care practices in Virginia found that the cost of the EHR, the lack of knowledge about its use, the transformation of office operations, major disruptions to patient care during system upgrades, difficulty using performance tracking, and lack of knowledge of EHR functions were among the barriers to meaningful EHR use.7

Similar findings were noted in other research studies. For instance, Menachemi and Collum reported that disadvantages of using EHRs in hospitals include the cost of EHR implementation.8 According to one 280-bed acute care hospital, the cost of its EHR was $19 million, which didn't take into account the maintenance often needed for hardware upgrades, vendor software, support fees, external contractors, and more. For instance, one small group of primary practitioners found that its maintenance costs averaged $8,412 per full-time employee.8 EHRs can create a loss in revenue because learning a new electronic system can cause frequent provider disruptions in work flow and a loss of productivity.8

A survey of over 7,000 nurses looked at nurses' experience using EHRs and found that they had many issues with documentation requirements in the EHR.9 (See What do nurses say are the challenges of EHR?) The comments made by nurses in the study included:

  • I got a nursing degree, but I'm really just a data-entry clerk.
  • We're “nursing” the medical record rather than the patient.
  • I need a stenographer to follow me around during my work and record everything I see, discover, think, evaluate, and do.
  • I “nurse” a computer instead of a patient, and it's made very clear that the computer input is more important than the patient.
  • I rest easy at night knowing I didn't sacrifice bedside care to click boxes on a screen.
  • In reality, we don't need to do anything at all for the patient, as long as we document that we did.
  • I never thought I would see the day when a machine would need to be cared for more than my patient.9

At my local hospital, nurses are encouraged to keep a list of EHR functions that they believe need to be improved. This list is shared with hospital leadership and the information technology team responsible for upgrading, revising, and maintaining the system. Even though nurses report many challenges when using the EHR, they also report some benefits.

Looking at the benefits

The nurses at the hospital found benefits to using the EHR similar to those cited in current research studies. Menachemi and Collum performed a qualitative research study and found that benefits to using an EHR included increased efficiency when retrieving medical information, improved sharing of patient information, and enhanced coordination of care and office operations.8

Another benefit of using EHRs is the potential for data collection to show healthcare providers which interventions are working and which are not. For instance, research has shown that interventions such as electronic reminders improve compliance with patient influenza and pneumococcal vaccinations and clinical alerts lead to a decrease in medication errors, improving current practice and transforming the delivery of healthcare.8

A process called data mining includes uncovering patterns and trends and using them to develop predictive models.10 Mining EHRs can potentially reveal unknown disease correlations.11 According to Koh and Tan,10 data mining can do the following:

  • assist in detecting insurance fraud and abuse
  • promote customer relationships
  • assist with management decisions
  • identify effective treatments and best practices
  • allow patients to receive improved and affordable healthcare services
  • help to analyze, transform, and process healthcare transactions.10

Using EHRs can help to decrease or even eliminate hospital-acquired conditions. For example, collecting data on central line-associated bloodstream infections can lead to the recognition of the number of infections in a healthcare facility, triggering development of strategies to prevent them. After strategies are implemented, their effectiveness can be more easily assessed by collecting electronic health data. According to Quan et al., the EHR can help providers assess the effectiveness of disease prevention strategies and raise current standards for best practice interventions.12 The study looking at the EHR experience of over 7,000 nurses found that 45% of nurses loved electronic charting, 26% felt they would eventually like it once they got accustomed to it, 16% were undecided, and 13% were having a hard time using it.9 The study also found the EHR use had benefits for both nurses and patient outcomes.9 (See What are the benefits for nurses and patients?)


Nurse leaders and clinical nurses must work together to look for ways to address the many disadvantages of using EHRs. The American Nurses Association (ANA) recognizes that nurses need to participate in choosing the EHR system they'll be using as well as the development, implementation, and evaluation of the EHR. The ANA further recommends that “attention and action of nurses, the professional and specialty nursing organizations, and the nursing profession [are needed] to ensure the EHRs are designed to facilitate and support critical thinking and decision making, such as in the nursing process, and the associated documentation activities.”13 Salanterä says that research in nursing documentation is needed so that big data analysis and nursing information can be used to improve patient safety and decision support.14

At my hospital, a collaborative team has been instrumental in addressing EHR issues and working to create a user-friendly system for nursing. As we continue to use EHRs and work together with staff members who frequently access and document patient records, the process should evolve to result in fewer than “59 clicks” being needed to update patients' care of plan. Healthcare leaders must ensure that a collaborative team of all stakeholders, including clinical nurses, continues to assess EHR effectiveness and efficiency so that nurses can spend more time caring for the patient and less time caring for the computer.

The bottom line

EHRs are part of almost every healthcare institution today and most likely are here to stay. Nurses' input is vital to ensure EHRs are easy to use and improve patients' outcomes. EHRs need to be a valuable resource that supports nurses in providing safe, quality care to patients.

What do nurses say are the challenges of EHR?9

  • Takes away from patient care
  • Requires extra time to document
  • Needs endless logging in and out
  • Requires paging through unnecessary screens
  • Creates redundant entries
  • Makes it difficult to locate something
  • Increases mandatory documentation
  • Lacks space needed to write a narrative
  • Doesn't provide an opportunity to transcribe patient care in one's own words
  • Takes the patient away from the scenario
  • Makes it easy to overlook something
  • Allows the wrong box to be clicked
  • Limits the full description of the patient
  • Requires items to be chosen from a menu rather than by using critical thinking
  • May impair the use of critical thinking
  • Allows errors to be made by copying and pasting
  • Creates confusion about what actually occurred with a patient
  • Often leaves out the interaction between the nurse and physician
  • Disconnects the nursing assessment from the nursing process.

What are the benefits for nurses and patients?9

  • Can help administrators analyze how patient care affects patient outcomes
  • Identifies areas of improvement needed in both nursing process and patient care
  • Maximizes reimbursement incentives
  • Meets quality care measures for the Centers for Medicare and Medicaid Services
  • Helps to identify best practice interventions to provide safe and quality care
  • Provides opportunities to analyze data about patient care.


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2. Health information privacy. HITECH Act Enforcement Interim Final Rule. 2017.
3. The Office of the National Coordinator for Health Information Technology. Health IT dashboard: quick stats. 2017.
4. Charles D, Gabriel M, Searcy TThe Office of the National Coordinator for Health Information Technology.. Adoption of electronic health record systems among U.S. non-federal acute care hospitals: 2008-2014. ONC Data Brief. 2015;23.
5. Electronic health records (EHR) incentive programs. 2017.
6. Siwicki B. CEO spotlight: former ONC chief Farzad Mostashari on EHR shortcomings and pop health potential. Healthcare IT News. 2016.
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13. American Nurses Association. Electronic health record. ANA position statement. 2009.
14. Salanterä S. Advanced use of electronic health records: the depth of nursing notes. Nurs Res. 2015;64(6):411–412.
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