59 clicks in the EHR : Nursing Management

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Department: Nursing Informatics

59 clicks in the EHR

Kroning, Maureen EdD, MSN, RN

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Nursing Management (Springhouse) 49(5):p 10-14, May 2018. | DOI: 10.1097/01.NUMA.0000532337.74937.a1
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When performing rounds as a nursing supervisor at an acute care hospital, I heard a nurse complain that it took 59 clicks in the electronic health record (EHR) to update her patient's care plan. 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 advantages of EHRs and elements that need further improvement.

Current state of practice

The Office of the National Coordinator (ONC) for Health Information Technology, a branch of the U.S. Department of Health and Human Services, was established in 2004 to manage and provide standards for the government's stimulus program. According to the 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

According to HealthIT.gov, advantages of 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 provides patient care.2

On February 17, 2009, the HITECH Act was signed into law.2 It was designed to promote the adoption and meaningful use of health information technology (IT) 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 with 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, three in every four U.S. hospitals have an EHR system in place.4 Both the Centers for Medicare and Medicaid Services (CMS) and the ONC require that professionals and hospitals use EHR systems that are certified by the incentive program. They also require adherence to standards and criteria to be eligible for the incentives.5 The ONC reported that as of June 2016, of 4,474 U.S. nonfederal acute care hospitals in the Medicare and Medicaid EHR Incentive Programs, 95% had the 2014 certified technology in place.2,5

EHR legislation has directly impacted nursing practice. When Farzad Mostashari, the former CEO of the ONC, 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've had a more active role in implementing the EHR in clinical nursing practice to make it more efficient for them to use. Healthcare professionals working at the bedside can't choose whether to use the EHR. Healthcare administrators need to be aware of what the nurses providing care and electronically documenting it consider to be the advantages and disadvantages of EHRs.

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, lack of knowledge about its use, 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 use.7

Similar findings were noted in other research studies. One study reported that disadvantages of using EHRs in hospitals include implementation cost.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 example, 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 their experience using EHRs and found that they had many issues with electronic documentation requirements.9 (See Table 1.) The comments made by nurses in the study included:

  • I've 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
Table 1::
Nurses' perceptions of EHR challenges9

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 IT team responsible for upgrading, revising, and maintaining the system. Although 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. One qualitative research study found that EHR benefits included increased efficiency when retrieving medical information, improved sharing of patient information, and enhanced care coordination and office operations.8

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

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

Using EHRs can help 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 the development of strategies to prevent them. After strategies are implemented, their effectiveness can be more easily assessed by collecting electronic health data. The EHR can help providers assess the effectiveness of disease prevention strategies and raise current standards for best practice interventions.12

One study of over 7,000 nurses found that 45% of nurses loved electronic documenting, 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 that EHR use had benefits for both nurses and patient outcomes.9 (See Table 2.)

Table 2::
Benefits for nurses and patients9


Nurse leaders and clinical nurses must work together 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 Nursing documentation research 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 plans. 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 patients 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 that EHRs are easy to use and improve patient outcomes. The EHR needs to be a valuable resource that supports nurses in providing safe, quality care.


1. ECRI Institute. ECRI Institute PSO deep dive: health information technology. www.healthit.gov/hitac/sites/faca/files/STF_Deep_Dive_Health_Information_Technology_2014-06-13.pdf.
2. U.S. Department of Health and Human Services. HITECH Act enforcement interim final rule. www.hhs.gov/hipaa/for-professionals/special-topics/HITECH-act-enforcement-interim-final-rule/index.html.
3. The Office of the National Coordinator for Health Information Technology. Health IT dashboard: quick stats. http://dashboard.healthit.gov/quickstats/quickstats.php.
4. Charles D, Gabriel M, Searcy T. Adoption of electronic health record systems among U.S. non-federal acute care hospitals: 2008-2014. www.healthit.gov/sites/default/files/data-brief/2014HospitalAdoptionDataBrief.pdf.
5. Centers for Medicare and Medicaid Services. Electronic health records (EHR) incentive programs. www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms.
6. Siwicki B. CEO spotlight: former ONC chief Farzad Mostashari on EHR shortcomings and pop health potential. www.healthcareitnews.com/news/ceo-spotlight-former-onc-chief-farzad-mostashari-ehr-shortcomings-and-pop-health-potential.
7. Goetz Goldberg D, Kuzel AJ, Feng LB, DeShazo JP, Love LE. EHRs in primary care practices: benefits, challenges, and successful strategies. Am J Manag Care. 2012;18(2):e48–e54.
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9. Stokowski LA. Electronic nursing documentation: charting new territory. www.medscape.com/viewarticle/810573_8.
10. Koh HC, Tan G. Data mining applications in healthcare. J Healthc Inf Manag. 2005;19(2):64–72.
11. Jensen PB, Jensen LJ, Brunak S. Mining electronic health records: towards better research applications and clinical care. Nat Rev Genet. 2012;13(6):395–405.
12. Quan KA, Cousins SM, Porter DD, et al. Electronic health record solutions to reduce central line-associated bloodstream infections by enhancing documentation of central line insertion practices, line days, and daily line necessity. Am J Infect Control. 2016;44(4):438–443.
13. American Nurses Association. Electronic health record. ANA position statement. http://nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-Statements-Alphabetically/Electronic-Health-Record.html.
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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