Why nurses need better EMR design to care for patients

There’s always a lot of stink from physicians over usability problems with EHRs: too many clicks, too many contextual menus, etc. The gist of these complaints is, “Physicians aren’t data entry clerks!” The computer is getting in the way of their interactions with their patients.

Everybody has a finite amount of mental space available at any given moment. Imagine having to transcribe a conversation in real-time. If half of your mental space is engulfed by real-time documentation, how much are you really paying attention?

It reminds me of this interview with Truman Capote on his decision to rely solely on memory when writing In Cold Blood:

Not long ago, a French literary critic turned up with a tape-recorder. I don’t like them, as I say, but I agreed to its use. In the middle of the interview it broke down. The French literary critic was desperately unhappy. He didn’t know what to do. I said, “Well, let’s just go on as if nothing had happened.” He said, “It’s not the same. I’m not accustomed to listen to what you’re saying.”

Many primary care physicians are tired of not being able to listen. They have begun hiring full-time stenographers to document patient encounters for them. They sit in an adjacent room listening in via a microphone. By the end of each visit, the documentation is complete, and the physician doesn’t have to touch a computer. I think this is a great idea. Documentation is not the priority during a patient encounter— afterwards, perhaps, it becomes paramount, but not during the event itself. The physician’s mind should be fully engaged with the patient.

So what about nurses? Aren’t we laboring under the same demand to eat our cake and document it, too? Do we have a legitimate argument to make about excessive and unnecessary documentation?

Nurses are expected to document innumerable facts: vital signs as often as every 15 minutes, turning a patient on his side, fluid intake and output, medications, IV patency, pain questionnaires, linen changes, baths, safety checks, dressing changes, physical assessments— the list is much longer than I have space to document here. The point is that all of these trivia are supposed to be entered into a computer for each patient by the end of each shift. Many nurses end up staying an extra hour or two after their twelve-hour shift ends just to enter in all the data of their day. This costs the hospital both in terms of money and job satisfaction.

But I am not advocating that we do away with this kind of documentation. Data entry is an essential part of every nurse’s job description. Physicians need the facts we document in order to make informed decisions about their patients’ care. Hospitals need the facts to measure cost-effectiveness and to demonstrate their commitments to safety.

Nor am I suggesting that hospitals hire herds of stenographers chasing after their nurses. No one else can do our documentation for us. There is no room for a stenographer at the bedside. My suggestion is that we turn to technology to help us.

Contemporary EMRs are notoriously unusable. All the complaints that physicians raise against them are also valid of the nursing modules. Too many clicks, too many contextual menus. All—all—EMRs are clearly designed by programmers with no understanding of nursing care. Their software is written at the behest of healthcare administrators whose primary concerns are compliance and cost. Workflow efficiency comes last, if it comes at all.

Contemporary EMRs are only contemporary insofar as they are being sold in 2010. As far as the technology they leverage is concerned, they are relics of the 1990s (or worse). They are endless tabs of little grey boxes and drop-down menus without any visual cues to separate the meaningful facts from the JCAHO-compliant fluff. Where are the iPhone and iPad apps? Where is the ability to email one-click-generated PDFs to another provider? What about task-awareness? What about multimedia? Hell, why can’t I paste a simple JPEG into my physical assessment?

But what of the other more subtle advances in technology? In the past thirty years, companies like Apple and Nintendo have been in a continual process of reinventing and refining they way that we interact with computers. Apple has even published a lengthy document detailing the human interface guidelines they encourage app developers to follow to make their apps more user-friendly. These kinds of documents are widely available. Why don’t EMR vendors take advantage of them? Could rounded corners and simplified interfaces really be that expensive? Wouldn’t ease of use be a marketing point that spurs widespread adoption?

I believe that if an EMR vendor were to incorporate best-of-breed UI design into an app built for portable touch interfaces like the iPad, it would allow nurses to fully document their day, in real-time, and in less time, freeing us to spend more time doing what we went to nursing school to do: care for our patients.

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

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