Nurses Adopt Electronic Health Records

Future of Nursing
Nurses Adopt Electronic Health Records
Esker-D Ligon with patient at Glide Health Services (photos by Elisabeth Fall)

As health care reform and federal incentives for “meaningful use” of technology have hospitals, clinics and physicians’ offices racing either to transition from paper or to update existing electronic health records (EHRs), nurses are carefully monitoring the effects of this technology on their ability to serve patients.

Recent studies indicate that the challenges are many and the learning curve can be steep, but in the end, there are clear benefits. Nurses are especially appreciative of how more and better information often fosters measurable improvements in everything from pneumonia and pressure ulcer prevention to more appropriate screening and better outcomes for patients with chronic conditions. A University of Pennsylvania study found that nurses working with EHRs consistently reported more improvements to nursing care and better health outcomes for patients than nurses working in hospitals without this technology.

The challenge is getting there from here. That’s why faculty and alumni from UCSF School of Nursing are among those synthesizing an emerging set of best practices that can ease the learning curve for those starting out, and indicate promising areas for improvement.

Marilyn Chow Marilyn Chow (UCSF School of Nursing ’70, ’72, ’82), vice president, National Patient Care Services at Kaiser Permanente, continues to be instrumental in Kaiser’s most recent EHR implementation, which is often cited as a national model. She also co-authored a book chapter on nursing’s role in the ongoing project.

“Today, [the country’s health care system] is going through a period of transition to using new technology such as EHRs,” says Chow. “We are already changing nursing practice for the better and, over time, we will continue to add value to what nurses can do.”

But adding value, say Chow and others, depends on participants remembering that all health information technology (HIT) projects are a means to an end, catalysts for change in how clinicians and their supporting institutions organize and deliver care.

Adding value also depends on gleaning important lessons from some of the difficult early implementations. The following considerations seem especially important.

Have Clear Goals and a Sense of Where You Are

Successful EHR implementations, says Chow, begin with framing the goals properly. She is particularly focused on using data to improve care. “If you don’t have a plan for how to mine your data to create new, evidence-based practices, then your build may not enable you to change nursing practice. The design of the build must address how you can retrieve meaningful data,” she says.

Patricia Dennehy, Chenin Kenig and Esker-D Ligon at Glide Health Services UCSF faculty member Patricia Dennehy, who directs Glide Health Services, a UCSF nurse practitioner-managed clinic in San Francisco, recently co-authored a paper in the Journal of the American Medical Informatics Association about Glide’s EHR implementation. She echoes what Chow has to say about the benefits of using data to improve care delivery.

Dennehy also notes the importance of understanding your existing system. “We were greatly hindered by a weak infrastructure in our implementation of an electronic system,” says Dennehy.

Involve Clinicians and Clinical Informaticists from the Outset

Another key lesson, say both clinicians and product vendors, is to involve doctors and nurses in product development from day one.

“I was called into one hospital system after its management and IT teams built their electronic record and then put it in front of the users,” says Terri Gocsik, an administrative nurse for many years, before becoming a consultant for Aspen Advisors, a firm that helps providers implement HIT. “They wound up pulling the plug and starting over with another vendor, this time involving clinicians in the design and build.”

“For us, the RNs, NPs and nurse scientists are an integral part of the clinic,” says UCSF’s James Kahn, who directed development of both HERO (Healthcare Evaluation Record Organizer) – a web-based electronic medical record system used at San Francisco General Hospital (SFGH)’s AIDS ward – and its companion piece, myHERO, a publicly accessible personal health record linked to HERO, for patients to learn about their health.

Gina Wade (left) Nurses’ involvement led to numerous modifications, including an urgent care note for a nurse-only visit. “We worked with nurses and certifying bodies to make sure we had all the different elements, populated with drop-down lists, and the note has made a real difference in nurse’s workflow and billing,” says Kahn.

Gina Wade (UCSF School of Nursing ’98), executive director for clinical informatics at Adventist Health – a large, integrated delivery system in the western United States – says that nurse informaticists can optimize the communications between clinical and IT teams, because they are taught to be the translator (read more about Gina Wade). Chow notes that Kaiser has had clinical informaticists aboard – both physicians and nurses – throughout its process.

Strike a Balance on Customization

Yet despite the importance of considering nurses’ workflow, all agree there is a tipping point beyond which further customization causes more problems than it solves.

Joanne Spetz “In some settings, the system was so customized that it became very slow,” says UCSF School of Nursing faculty member Joanne Spetz, who has run studies on the effect of HITs on nursing. “When a system changes workflow, the real need might be for better training, rather than more customization.”

Chow agrees and notes that without some careful, standardized elements, the goal of harvesting data is compromised. “Good analytics need the most discrete data element identified – not just apples to apples, but pippins to pippins,” she says. “I really pushed for a consistent build in our inpatient record and initial assessment across our 36 hospitals, so if we’re talking about pressure ulcers, stage 3 and 4, you can see what set of interventions actually led to a faster healing process.”

Besides, says Gocsik, with the pressures of federal “meaningful use” standards – the Centers for Medicaid & Medicare Services (CMS) requires providers to show they’re using federally certified EHR technology in measurable ways – customization options are increasingly constrained. “Software vendors are trying to meet government-imposed regulations and timelines, which means they can’t focus as much on user-group feedback as they did in the past,” she says. 

Prepare the Staff

Regardless of the degree of customization, all agree it’s important to do as much as you can ahead of time to prepare users for changing workflows. “You have to figure out how new technology will help or change clinical processes and train staff accordingly,” says Spetz. A combination of classroom education, self-directed practice, superusers and parallel workflow can all help in the preparation process so that when the system goes live, nurses are relatively comfortable and don’t need to take 10 steps back.

Darlene Lee in the UCSF Rheumatology Clinic “We scheduled a number of ‘rah-rah’ meetings, but we were also very practical,” says Nurse Practitioner Darlene Lee, who manages the Rheumatology Clinic at UCSF Medical Center, where a new EHR system began operating in July 2011. “Each of my staff diagrammed their workflow and we identified where it would impact them, so they were fully engaged by the time the system actually came around.”

“I think it’s critical for nurses to get involved,” says Wade. “It’s also important for them to understand that often what is coming in EHR is driven by regulatory requirements. If you don’t keep up on what you need to do for certain disease conditions, you won’t understand why it’s in the system.”

Anticipate Resistance

While up-front preparation is critical, nurse administrators still need to anticipate resistance at every point along the way.

Sometimes that resistance stems from nurses’ sense that systems appear to be geared toward doctors’ workflows. Gocsik says that in many cases, that perception is reality.

“We’re asking physicians to do things that are coming right out of their pocket, and we have to look at minimizing the productivity risks for them,” she says. “That doesn’t mean we can’t listen to nurses or their concerns are unrelated, but there has to be sensitivity on nurses’ part.… The more we can have interdisciplinary teams, the more we can have a win-win situation.”

In addition, says Spetz, “We know there tends to be less resistance among nurses who are more tech savvy,” those who grew up with a computer, are able to type quickly and are comfortable clicking around a screen. “People need to understand their staff and bring the less tech savvy along.”

Part of that is helping people understand how the system will benefit them. “The value of the change needs to be understood, and that value is different for each person who touches the system,” says Dennehy.

Sometimes, however, understandable resistance can be addressed by a discussion of the greater good. At SFGH, clinician diagnoses automatically populate the patient’s personal health record, which raised concerns about patients viewing some more controversial clinician notes. Through open discussions, says Kahn, the team finally decided that the need for transparency outweighed the concern; the key was helping staff have appropriate discussions with patients.

Gird for the Initial Weeks

In the end, no matter how well prepared a team may be, people need to expect that the initial weeks will bring a drop in productivity. “We are continuously stunned that some people don’t assign any extra nursing staff during this time,” says Spetz. “Organizations should assume there needs to be a trainer or superuser on site 24/7 and at least one extra nurse for every shift.”

Esker-D Ligon, a nurse practitioner and director of behavioral health services at Glide, says, “At first, it really did impact the level of care we were able to provide. Along with hiring temporary staff to load up information from the paper charts, we had to take provider schedules down.”

The UCSF Rheumatology Clinic went to half-time schedules for a few weeks. “What you learned in class was nowhere near enough for what you needed in the real world,” says Lee. “Having trainers on-site helps, but when you have a live patient and feel pressured to make eye contact and do this at the same time…it’s a whole new way of dealing with the patient.”

Understand the Impact on Patient Interactions

The eye contact issue raises another concern many nurses have expressed: what are the subtle effects on patient interactions? Three overlapping challenges seem to be at play.

Time is one. Research has demonstrated that nurses spend more time inputting information with EHRs, but less time finding the information needed to make wise decisions. Usually, that clinical information is also more complete and more accurate than it was with paper records.

That said, for home health nurses who must race from one setting to the next over their day, the time issue can be particularly vexing. “The inputting of information definitely puts pressures on,” says Barbara Maury of UCSF Home Health Care. “But ultimately getting the data into the computer correctly will be the best for patient care, so we try to address the time pressures by carefully keeping our nurses in a certain geography to cut down on travel.”

A second concern is that computer screens could become physical barriers between nurse and patient. “I show both nurses and doctors how to create a triangle between you, the patient and the computer screen,” says Kahn. “You can then use the screen as a blackboard, a teaching moment, a way to actively engage patients in health care.”

Lee uses a similar approach, and Ligon says, “Patients aren’t that bothered if you explain you have to do the documentation on the computer…. They like the fact that you’re putting in information as you go along. They feel heard more.”

Third, some nurses have worried that templates will foster a robotic effect on their clinical judgment. Chow believes this can be addressed through time and education – and it is similar to some past challenges.

“When we would teach students in the pediatric nurse practitioner program, we’d find they were so worried about the physical exam – where they were placing a stethoscope – that they couldn’t focus on engaging with the mom. We realized we had to first get them comfortable with the physical exam,” says Chow. “It’s the same thing here. There will be a period of adjustment, but as we get better at streamlining the documentation, problems will ease and nurses may actually have more time to interact with patients.”

Strive for Interoperability Across Settings

To truly achieve the type of change that health care reformers seek, tighter clinical integration across practice settings is a must. Systems have to talk with each other to gather the clinical information they need. This is the thinking behind health information exchanges that will store and communicate patient data across multiple health systems.

“Fully integrated systems like Kaiser and the VA have unique advantages addressing transitional care issues,” says Spetz. “At this point, the independent or rural hospital rarely can access what goes on in ambulatory settings and vice versa.”

Even at Kaiser, says Chow, the transition from hospital to ambulatory settings “is not as seamless as we’d like yet. We’re constantly asking, What is it that nursing needs to assure there is good transitional care between settings? I don’t know that any system has that fully figured out yet.”

Glide and other community clinics and hospitals in San Francisco are trying. “Right now, if we identify ourselves as the primary care provider within the San Francisco Community Clinic Consortium, we actually get email notification if a patient is in the ER, which triggers us to look for a report,” says Dennehy. “Hopefully, next year we would be notified that information was available and be able to log in to a secure portal for the information in a format that we could import directly into the patient’s health record.”

Keep an Eye on Information Overload

For all the advantages of having more information at one’s fingertips, nurses and others have begun to voice concerns about information overload.

“In designing these systems you have to think about our ability to retain and incorporate information; things can get to the point where a nurse isn’t seeing the important information clearly,” says Chow, who believes this is an important area for research. “We need to create [decision support] systems that have a limited number of logical triggers and alerts that focus entirely on what the nurse is going to need to know, so that the nurse can focus on the patient.”

Expect Nonstop Changes

All of the above concerns lead to one that many organizations tend to overlook: the need to see EHR/HIT implementations as a process of continual quality improvement (QI).

“Ongoing training is a big concern and a hidden cost,” says Dennehy. Glide is especially affected by this because it’s a teaching facility, with 12 to 13 nursing students a quarter, and so has needed to retain someone full-time just to get those students on board with the new EHR system.

But more than that, in every setting, issues pop up regularly. To address this, a consistent theme is the need for open lines of communication, clear governance processes and regular meetings. “We find that until we talk about it, we may not know that my colleague next to me is doing something differently,” says Glide Nurse Practitioner Chenin Kenig.

“You have to make a commitment to an ongoing process, across the board and from all levels of participants,” says Dennehy. “We’ve had a QI team since our clinic opened; implementing this tool is not the only change event in our history, and we understand the commitment.”

Measure the Impact on Patient Care

The good news is that those who make the commitment are finding improvements in patient care. “The documentation has increased so much in the favor of patient care that any learning curve is worth it,” says Kenig. “Patients are 10-fold safer.”

At Glide, two years ago, diabetic patients’ HbA1c count was typically in the 8 percent range, with the national average around 9 percent. Today, at Glide, HbA1c counts are at 7.7 percent. In addition, says Dennehy, blood pressure screening has improved. Mammographies are up, as are colorectal exams, flu shots and screening for smoking and depression. Kaiser has had similar improvements in population care as well as at its hospitals, where reductions in pressure ulcers have been documented, says Chow.

“It’s a tool for us to track chronic conditions in a way we never did before,” says Dennehy. “In one meeting, we can do short, PDSA (Plan-Do-Study-Act) cycles, notice that we haven’t tested lipids in a diabetic frequently enough, see why we fell off, and then quickly adapt. We could never do that when the information was buried on paper charts.” Moreover, she says, they can show trends on individual patient charts and share those with patients.

In addition, Kenig and Ligon talk about being able to compare their patients’ results with others at the clinic and then have a discussion about different practice patterns for different diagnoses and risk factors – and the effects on patient care. “We can really evaluate how we’re using our visits.… You have to have some strong providers and trusting communication, but this can have a very good effect on care,” says Kenig.

“I think we all have a stronger awareness of the whole patient; I can see what happens in the ER, in general medicine,” says Lee. She tells of a patient who had a rheumatoid arthritis flare the previous weekend, while Lee was out of the office. “I could just pull her chart electronically and e-prescribe prednisone; I could never have done that before.”

“I love the EHR,” says Maury. “Being able to extract information and communicate with other providers quickly, being able to print out a medication list with 15 meds with the press of a button is huge.”

Looking Ahead

Perhaps what’s most exciting is that EHRs still have an enormous amount of untapped potential. “As you get more and more sophisticated, you can use the system so much more efficiently,” says Lee. “Your understanding is constantly evolving.”

“Where we have to go is decision algorithms to digest all this information from so many sources. Researching how to do that effectively and the implications it will have for nursing care is very, very important,” says Chow.

Kahn believes there will be an enormous leap forward when patients become fully integrated with the system. “Until now, providers have had a choke point on health information, but if we can demystify health information through personal health records, we can help make patients more responsible for their own care,” he says.

Yet even in these relatively early days, with their many pitfalls, the universal sense from this group is that EHRs have already begun to transform nursing care and the entire health care system for the better.

“Even in our worst moments – we had some dreadful moments in terms of connectivity – there was a commitment to continue, because from the get-go, we knew it would be absolutely transformative,” says Dennehy. “Besides, there’s no turning back now.”

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