How EMRs are failing nurses

Among the litany of complaints about the (un)usability of EMRs, it’s easy to lose sight of the big picture. More than the poor design choices and overall ugliness of existing software, by far the single biggest failure of HIT companies is that none of them has yet to produce an EMR that nurses actually need.

There is a huge opportunity being wasted here. Other industries have been able to incorporate computers in such a way that removing them from the workplace would be unthinkable. Photographers and musicians are producing high-quality content in less time and with less money in digital studios. Executives are monitoring every aspect of their businesses, from supply chain logistics to sales, in real time, even while on the go. President Obama made the Blackberry a non-negotiable component of his administration.

We’re not dreaming big enough. The intrinsic value of technology is it’s ability to provide solutions to problems we never knew we had. Remember having to tell the neighbor to get off the party line so you don’t miss an important call? Remember not being able to go out on the weekend because the banks don’t open until Monday and you have no cash? I don’t. A few bright minds solved these problems for me before I ever knew I had them.

Other than billing or records, what problems does an EMR really solve? In their current state, EMRs add nothing of value to our work as nurses. They are tedious chores at best, outright obstacles at worst. They are database portals where we type some numbers and check some boxes, and nothing more.

Meanwhile, our nation’s nurses continue to take and receive shift reports on folded up pieces of printer paper. They place bits of silk tape on door frames to remind them of pending lab draws. They sometimes give scheduled medications late because their iPhones don’t have EMR apps that might take advantage of iOS 4’s support for local notifications and beep them at the proper time. They lug around laptops bolted to enormous rolling carts or wait in line for a free desktop PC because they can’t chart their morning assessments on the iPod Touches in their pockets.

Nursing is a profession of the clock. It is task-oriented. It has a lot of routine. It consumes data as fast as it can produce it. In other words, it is exactly the kind of job that cries out for a technological revolution.

Jared Sinclair is an ICU nurse who blogs at jaredsinclair + com.

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  • jsmith

    Jared’s analysis seems reasonable but is deeply flawed. Nursing, like medicine, is a human profession, not a data entry one. Here lies the problem: nurses, like doctors, are being asked to do two jobs in one, with a limited amount of time and constant interruptions. Indeed, it is worse than that. Often, one of the two jobs, buffing the computer, is a positive hindrance to what we do for a living. Why give report with a slip of paper? Because it’s faster and just as effective. Using a computer for this is a waste of resources. It sounds counterintuitive, but it is true. And it is the same for a lot of the stuff we do in HC.
    The trap that many people fall into when thinking about computers in HC is that they think if IT works in some industries and for some tasks, it works for all. This is simply not true.

  • http://www.emrandhipaa.com John

    I’d say that part of the problem has been nurses demanding software that does certain tasks. If there’s no demand, then there’s no solution offered. So, I’m glad to see a post like this that starts to ask the questions and demand that technology be implemented for nurses.

  • Marc Gorayeb, MD

    The truth is revealed. Electronic health records are for the benefit of people other than those required to enter data into them, and those required to take care of patients. I never had a problem reading hand-written nursing notes. Now I can’t find them when I need them because they are not on the chart. Orders entered electronically by nurses also don’t make it onto the chart, because it’s duplicative work that people resent having to do. So I don’t know what’s been ordered when I pick up a chart and go in to see a patient, and there’s no way for me to sign off on the orders.
    Now that the government is in the picture, there will be financial coercion, legal coercion, in addition to employer coercion to perpetuate this fiasco.

  • http://www.praxisemr.com Dario Bard

    I think Marc hit the nail on the head. The big players in the EHR game are creating software for the benefit others, not doctors. There are, however, smaller, lesser-known players that are bringing innovative ideas to the table. I think a good indicator of the usability of the program is to look at who is behind it. Among the small innovators, there are a few EMRs conceived by doctors who arrived at the same conclusion that Marc did. FULL DISCLOSURE: I work for one of them, Praxis: The Template-Free EMR. And Praixs is being used in nursing programs at Greenville Tech and the Galen College of Nursing. Also, we are starting to work with a high school in Florida that has an elective program where the students do rounds as nurse assistants. Because our CEO is a medical doctor, he is sensitive to the needs of the end user. The truth is that, although most EMRs are indeed using the power of computers for the benefit of others, there are a few that are harnessing it for the benefit of those that actually practice medicine, and that, of course, includes nurses.

  • Chris Keller, MSN, RN

    IF anyone could make a convincing case for enhanced patient safety, I would be more willing to use the troubled IT computer charting systems. However, I have NOT been convinced about patient safety being enhanced.

    Instead, I have experienced more of a task orientation in my nursing practice; and hand-in-hand with more tasks, I have less face time with my patients.

    I have seen change happening at such breakneck speed that nurses, doctors, pharmacists and ancillary staff are reeling. We are unsure that all the bases are covered–does the doc, does the pharmacist, does the nurse really know how to use this program to enter, to review, to check off orders? I am constantly asking myself and others–Did I/we forget something?

    Creative thinking should indeed apply here, as Jared says
    to address what nurses need. Every nurse needs a secretary to help her with multiple tasks and multiple details. Can EMR be a secretary to a nurse? Can the electronic device “follow” the nurse from patient to patient, the nurse tossing over her shoulder a request such as “This patient is still in pain, though it is 2 hours post pain med administration. Let’s look at another solution for her pain.”
    A voice recognition system would detect the term “pain” used 3x, and click into the MAR (medication administration record) where the nurse could now call out the number on the pain scale, given her by her patient, thus following up on pain assessment, one of the nurse’s primary tasks. The nurse would not have to turn away from her patient to enter data on the keyboard–the keyboard being one of the dirtiest surfaces in the hospital. It would be voice-recognition technology. Other options would pop up on a screen–such as documenting the last dose and additional pain medication (fetched by a pharmacy tech, not necessarily the nurse), or contacting the physician for new orders.

    The nurse would preserve her most important nursing skills: assessment and patient teaching. She would not have to look away from her patient to type on a keyboard. She could ask questions, get answers, examine wounds or casts or IV sites–getting more face time, direct patient contact. She calls her assessment findings to the voice-recognition computer behind her. She commands “Call Dr. XYZ with this assessment. Get a change of medication or another dose in a timely way–in the next hour” and the technology places the call with the nurse’s message as a robo-call.
    The doc does his CPOE (computerized physician order entry) and the nurse is notified via a phone signal, say two dots and a dash . . .

    For security, the nurse has a 3- or 4-digit password–to everything that she needs: computer, keypads in doorways, etc.

    The nurse tells the secretary computer program to fetch water, food, blankets, towels, lotion, soap. The secretary computer program notifies ancillary personnel when they can come in to make the bed, or if the patient needs an assist to the bathroom. “Please come in and empty the trash and clean out the sinks,” the nurse says.

    “This patient is at risk for falling,” the nurse says, and ancillary personnel increase their monitoring and offer their assistance in getting out of bed. The nurse gets 3 dots and 2 dashes whenever that patient is getting out of bed . . .

    The nurse is not interrupted by non-essential phone calls when she is with a patient or when she is checking meds.
    The computer program calls out or pops up the “5 Rs” for med safety whenever the nurse goes into the MAR.

    Etc. Oh, by the way, have you as a nurse, or have I, as a bedside nurse, ever been asked what our ideas are for enhanced safety, security, streamlining? I, for one, have not. This is the first time.

    Don’t bother me with EMR experimentation. It is a waste of my time and focus. I want my “scraps” of paper in my pocket where I have a summary of my patients’ needs. I call it my “brain”. EMR IT has not replaced it in any kind of reliable manner.

    It is ME, personally focusing and being my best professional self, that keeps my patients safe. Invest all the $$$ that is going into EMR/IT in to ME, to help me become more aware of safety issues, to be a better and better professional nurse.

  • http://diagnosticinformationsystem.com Bob Coli, MD

    One of the biggest failures of all EMR and HIE HIT platform vendors is their continuing use of flawed variable formats to report the results of billions of annual diagnostic tests as fragmented, incomplete data that disrupts the workflow of both physicians and nurses.

    The logical solution is using a standard format to report all 6,500 different cumulative test results as clinically integrated, complete information that is easily viewed and shared on up to 80 percent fewer screens.

    In response to the industry-wide unmet need and its commercialization potential, I am one of a group of private office-based physicians using an open collaborative innovation business development model to dramatically improve the usability, viewing and sharing of this vital clinical patient information.

    This is more likely to happen if the existing sellers market for HIT products can be transformed into a consumer-centered buyers market, where vendor success will depend on competing for the business of each new generation of clinicians and nurses based on product usability and overall value.

  • David Hager, M.D.

    I agree with Mr. Sinclair and echo his sentiments here:
    http://www.ama-assn.org/amednews/2010/10/18/edlt1018.htm

  • http://www.jaredsinclair.com Jared Sinclair, RN

    Dr. Hager wrote:

    “Clinicians want a usable, reliable, secure, affordable EHR system that feels intuitive and smooth and makes us work faster, smarter, safer and more profitably at the point of care. Give clinicians these things, and federal incentives won’t be needed. The phenomenon of smartphone adoption by physicians is evidence of our spontaneous willingness to adopt usable, useful technologies.”

    Precisely.

  • gzuckier

    It’s an extension of current trends; look how the adoption of ICDs and CPTs to “earn” reimbursement has changed the way people practice medicine. As humanity becomes more and more organized people and their doings have to become more and more little interchangable modules so they can be managed easily.

  • Chris Keller, MSN, RN

    Jared challenges us to dream bigger, to solve problems we never knew we had. Creative thinking is needed–though it is hardly possible when nurses are as task-oriented as they are forced to be. Instead of herding nurses into “shared governance” committee work, with topics assigned by managers, not front-line nurses; create open-ended brain trusts of nurses in each health care organization. Say the phrase “lugging around laptops bolted to enormous rolling carts,” and let the brain trust nurses free-associate–and be prepared to marvel at the wisdom and the creativity that comes out of their mouths. Suggest the word “interruptions,” and see what the nurses say. Say the term “face time,” and see what they offer. I guarantee that there will be clear analysis, outstanding problem solving, ethical dilemmas defined . . .
    Wake up! nurses are SMART. Practical-smart. They are on the front lines–they KNOW the needs, what is lacking, what works and what is subterfuge. They can tell you what patients are saying–way ahead of the analysis of the surveys that come in after discharge. They also read cues, and can see patterns, detecting an unspoken criticism or disappointment in a patient or a patient’s family.
    I got an email last evening from a friend who went to the ER with a migraine and out of pain meds. Of course he was regarded as a medication-seeking patient. He said the nurse didn’t even look him in the face for 5 minutes, but relied on a monitor to assess him/his needs. He left without even a single dose of any type of pain medication–they told him they believed he was/would be an addict. I’ll bet it is all nicely documented via CPOE, nursing assessments, and is in compliance with HIPAA standards, and billing info in order . . . but the patient’s pain was NOT addressed . . . Is this the real deal? Is this genuine nursing and medical care? Is this any kind of care at all? My friend didn’t feel cared for . . . He left as he came, in pain. We are missing the mark, folks.

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