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Department: Nursing Informatics

The electronic health record and patient-centered care

Cline, Laura BSN, RN, CEN

Author Information
Nursing Management (Springhouse): March 2020 - Volume 51 - Issue 3 - p 6-8
doi: 10.1097/01.NUMA.0000654880.27546.6a
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Electronic health records (EHRs) are consistently used by external organizations to track the quality of care provided based on the information documented in the medical record, which affects hospital accreditation and reimbursement.1 However, there's concern that technology may cause some patients to feel as if nurses and other practitioners are documenting for the institution instead of caring for them.1 Therefore, with the integration of bedside nursing and EHRs, nurses must understand the impact of technology on patient-centered care to safeguard the dynamic relationship between the patient and nurse.

The National Academy of Medicine (formerly the Institute of Medicine) defines patient- and family-centered care—also called person-centered care—as care that's planned, delivered, managed, and continuously improved in active partnership with patients and their family to ensure integration of their health and healthcare goals, preferences, and values.2 For patient-centered care to be effective, nurses must use technology effectively. This article examines patient and practitioner concerns surrounding EHR usage and proposes recommendations for improvement.

Literature review

This author conducted a literature review using the PubMed database with the following search terms: patient-centered care, nursing, technology, electronic health record, and impact. The review revealed a mostly negative connotation associated with the use of EHRs in healthcare.

According to Hunt and colleagues, many practitioners don't believe that EHRs capture the full extent of the patient's healthcare needs.1 Instead, they require practitioners to fit the patient's signs and symptoms into premade boxes that may not accurately represent the complexity of his or her clinical status.

An article by Dillard-Wright suggested that the creation of EHRs shifted nursing priorities from being patient-oriented to task-oriented and inadvertently decreased nurses' ability to think critically.3

Additionally, a nursing survey found that most nurses were unhappy with EHRs and didn't believe the information technology department was able to develop an adequate and beneficial documentation system focused on patient care.4 According to Hoover, nurses feel that EHRs are time-consuming and decrease time at the bedside.4

Moreover, as EHRs relate to data collection, they've shifted the focus from the patient to institutional and organizational priories.5 For example, a review by de Ruiter and colleagues mentioned the development of the Braden Scale and the requirement to document patient repositioning every 2 hours to prevent pressure injuries as institutional priorities rather than patient-centered ones.5 The Centers for Medicare and Medicaid Services won't reimburse institutions for expenses related to certain preventable adverse events such as hospital-acquired pressure injuries. Consequently, nursing care and documentation are often dictated by the institution's financial interests and not necessarily by patient-centered care.

A study by Asan and colleagues found that patients also had an unfavorable view of EHRs, perceiving that the practitioner focused more on the screen than them.6 Hunt and colleagues suggest that the negative view of EHRs is further accentuated by practitioners asking repetitive questions and questions not pertaining to the patient due to the requirement to check off boxes.1

In addition, Asan and colleagues found that patients weren't in support of providers using the EHR if they felt that the practitioner was focusing too much on the computer, didn't make eye contact, didn't listen, or typed excessively.6 Conversely, patients were comfortable with the practitioner using EHRs if he or she made good eye contact, focused on them, and listened.6

As suggested by Zhang and colleagues, patient-centered care is achieved in part by communicating effectively, engaging the patient, and providing adequate eye contact to help build rapport and trust. By incorporating those actions, nurses are better able to partner with patients, respect their preferences, and support them through medical decisions.

For practitioners, the use of technology allows them to monitor patients remotely and offers built-in safeguards to alert them to critical results and evidence-based practice recommendations. At its best, technology can help decrease errors, permit patients and clinicians to communicate, and give patients access to their test results at home.7 A study by Hessels and colleagues found that the use of EHRs also helped decrease readmissions and reduce lengths of stay.8

However, the literature reveals that technology alone wasn't enough to increase patient satisfaction. In fact, nursing support, adequate staffing, resources, and technology all need to work together to provide quality patient-centered care at the bedside.8 Overall, a disconnect between technology and patient-centered care as it relates to healthcare was apparent.

Because most of the literature discusses the relationship between physicians and patients, there's a gap in the literature on this topic as it relates to nursing. Furthermore, few studies discuss how nurses can become engaged in contributing to changes within EHRs to improve overall nurse and patient satisfaction. Objectively measured research on patients' perceptions of patient-centered care was also limited. Most important, a literature gap was found relating to how nursing may facilitate patient-centered care in association with technology to improve patient satisfaction, patient outcomes, and healthcare in general.

Integrating technology and patient care

These findings have important implications for nursing education. For example, nursing instructors need to educate their students about the impact of technology on bedside nursing. Instructors must incorporate solutions for integrating technology and nursing care during their lectures and clinical rotations. Moreover, students must understand how EHRs contribute to healthcare reimbursement and how technology may be used to involve patients and encourage them to take control of their own healthcare.

For clinical nurses, EHRs have been associated with a shift from providing patient care to ensuring that all documentation is correct and completed. Most documentation requirements have been created for the purpose of meeting the institution's priorities, such as reimbursement, billing, quality, safety, and accreditation standards. Because nurses are the primary providers of bedside care, it's imperative that they understand how valuable their input is with regards to electronic documentation. Nurses must encourage their organization to engage them in EHR formatting so that EHRs accurately reflect nursing care and facilitate workflow and ease of use.4

According to Frampton and colleagues, the focus on the patient and family creates a general atmosphere of improved care and increases patient satisfaction.2 Educating patients at their literacy level, providing empathy and compassion, and involving them in all decisions have also been proven to positively affect healthcare outcomes. Because nurses interact with patients the most, those who understand the effects of technology on the care being provided are in an advantageous position to ensure that it's being developed and used in ways that support and encourage patient-centered care.

Recommendations

Based on the literature, nurses can use multiple techniques to integrate technology and patient-centered care. For example, Asan and colleagues suggested that clinicians share the computer screen with patients.6 Allowing patients to see their EHR may improve their involvement and foster education. In addition, it allows for a sense of collaboration with the healthcare team and inspires trust and confidence in the care provided.

Another suggestion is to improve the layout of treatment rooms. The study by Asan and colleagues showed that patients and practitioners felt the typical layout of treatment rooms is inefficient for documentation and patient care. By reorganizing the room, a computer can be positioned so that the nurse can see the screen while also maintaining eye contact with the patient. In addition, placing a stool in the room allows the nurse to sit and talk with the patient while using appropriate nonverbal communication such as touch. In nursing, the act of sitting while talking with patients encourages patients to share information and engage in their healthcare. It also shows patients that the nurse wants to take the time to talk with them and provide holistic care.

Healthcare professionals can also stop typing while talking with the patient. One study found that making eye contact with the patient before and after typing improved patient satisfaction.7 Also, simply explaining to patients beforehand about computer use helps them know what to expect. In addition, multitasking while talking with patients may cause them to feel as though they're unimportant or the nurse isn't listening to them and their concerns.7 By learning to actively listen to patients, nurses can convey empathy, compassion, caring, and strong verbal and nonverbal communication. Active listening also promotes respect and support for patients and their healthcare.

These recommendations may be used in nursing education for both students and staff development. With the advancement of technology and the focus on patient-centered care, instructors can educate their students on therapeutic communication and interacting with patients despite the demands of technology. Instructors can provide their students with the skills to incorporate technology into their patient care in a way that benefits the patient. (See How technology can benefit patients.) If students can learn these skills while they're in school, they can transition them to the bedside and help educate experienced nurses about effective techniques.

For staff development, organizations should encourage their nurses to participate in meetings about EHR technology and make suggestions for improvement. In addition, administration should be sure to include clinical and nonclinical nurses in the design of new electronic documentation, as well as any updates and necessary training.4 By actively involving nurses in technologic updates, organizations can improve nursing satisfaction, patient care, documentation, and healthcare in general. Involving nurses also empowers them to contribute to their profession in a way that positively impacts nurses and other clinical staff, the organization, healthcare, and, ultimately, the patient.

Final thoughts

Despite its drawbacks, technology is a tool to help nurses work with their patients, engage them in their healthcare, and educate them to make informed healthcare decisions. Technology doesn't have to hinder the nurse-patient relationship. Nurses have the unique ability to improve patient care by getting involved and helping to develop electronic documentation systems that enhance patient-centered care.

How technology can benefit patients

Technology can help patients get involved in their healthcare. For example, nurses can share quality websites with patients and encourage them to research their disease processes. In addition, nurses can educate patients on obtaining their medical records online and communicating with their healthcare team electronically. Applications can be downloaded on cell phones to help empower patients to make healthy choices regarding their health and well-being. As nurse leaders, we need to find ways to help nurses balance institutional documentation requirements with patient care and education.

REFERENCES

1. Hunt LM, Bell HS, Baker AM, Howard HA. Electronic health records and the disappearing patient. Med Anthropol Q. 2017;31(3):403–421.
2. Frampton SB, Guastello S, Hoy L, Naylor M, Sheridan S, Johnston-Fleece M. Harnessing evidence and experience to change culture: a guiding framework for patient and family engaged care. National Academy of Medicine. 2017. http://www.nam.edu/harnessing-evidence-and-experience-to-change-culture-a-guiding-framework-for-patient-and-family-engaged-care.
3. Dillard-Wright J. Electronic health record as a panopticon: a disciplinary apparatus in nursing practice. Nurs Philos. 2019;20(2):1–9.
4. Hoover R. Benefits of using an electronic health record. Nursing. 2016;46(7):21–22.
5. de Ruiter HP, Liaschenko J, Angus J. Problems with the electronic health record. Nurs Philos. 2016;17(1):49–58.
6. Asan O, Tyszka J, Fletcher KE. Capturing the patients' voices: planning for patient-centered electronic health record use. Int J Med Inform. 2016;95:1–7.
7. Curran HJ. Fostering therapeutic communication while inputting data into the electronic health record. Nurs Inform Today. 2016;31(1):4–16.
8. Hessels A, Flynn L, Cimiotti JP, Bakken S, Gershon R. Impact of health information technology on the quality of patient care. Online J Nurs Inform. 2016;19(3):1–19.
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