Electronic medical records (EMRs) can be polarizing: Some people love them, some people hate them. However, there is concern among some healthcare professionals that there is more to the issue than personal preference. EMRs can be so time-consuming that nurses spend less time with the patient, critics say, and that change could threaten patient safety.
The burden of entering so much data in the EMR rather than caring for the patient is one reason Teri Dreher, RN, CCRN, iRNPA, left hospital nursing after 40 years as an intensive care nurse. She is now owner and CEO of North Shore Patient Advocates, a Chicago company that provides assistance to patients with navigating the healthcare system. The time required for documentation has long been a complaint of nurses, and Dreher notes that even 15 years ago, a nurse working a 12-hour shift would spend about two hours on documentation.
The introduction of EMRs only made the problem worse because much of the data entry is duplicative, Dreher says.
“When I left bedside nursing last year, we were tracking it and found that nurses were spending six to eight hours of a 12-hour shift doing computer work,” she explains. “It’s common sense to me, as a seasoned ICU nurse, that when you take doctors and nurses away from the bedside, you’re not going to get safer patient care. I think that’s one reason medical error rates are not getting significantly better.”
Dreher says many of the EMRs in use at hospitals are cumbersome for nurses to use. She says, for example, that when she left her hospital last year, getting medication to a patient required 14 steps of data entry in the EMR or the drug inventory system.
“What’s really happening is that nurses are just learning to override the system. It’s just override, override, override, because when the patient is in pain, the nurse is caught between relieving the patient’s suffering versus taking care of the computer,” Dreher says. “The systems that are used now are just ridiculous. Every nurse that I know who is still working in healthcare is greatly frustrated with EMRs.”
COMPUTERS DISTRACT NURSES
Dreher has seen nurses neglect patient needs because they were so focused on the EMR. She recalls one incident in which she helped another experienced ICU nurse admit a lung cancer patient to the unit. The woman was to be the other nurse’s patient, but Dreher helped get the patient settled while the other nurse took care of the EMR. After getting the patient set, Dreher notified the other nurse that the patient needed to be intubated. The other nurse was looking at the computer screen but said she would intubate the patient.
“I came back 15 minutes later, and she was still at the computer making sure she had all the bells and whistles covered. I walked in the patient’s room, and she was turning blue. I had to call a code and have the patient resuscitated,” Dreher recalls. “This was an experienced ICU nurse, but she was so consumed with making sure everything was right in the computer that she was neglecting her patient.”
Not everyone agrees that EMRs monopolize nurses’ time or threaten patient safety. On the contrary, EMRs can allow nurses to spend more time with the patient and patients’ family members, says Akram Alashari, MD, a surgeon working in general surgery, surgical critical care, and trauma at Grand Strand Regional Medical Center in Myrtle Beach, SC.
Contrary to Dreher’s experience, Alashari says clinicians spend less time typing in the electronic record than previously with handwritten notes. Time also is saved because the EMR means no time is spent searching for the written chart and no time spent waiting for other physicians and consultants to document in the chart. EMRs also improve care because physicians and nurses can review labs and images in the patient’s room, which allows them to interact with the patient in real-time.
Most complaints about EMRs monopolizing clinicians’ time make a false comparison between using an EMR and doing little or no documentation. From that perspective, EMRs do consume a lot of time. However, the real comparison must be to the non-EMR alternative, which was the voluminous paperwork of yesteryear, Alashari says. People actually are complaining about the documentation burden, not the use of EMRs, he says.
“I hear a lot of complaints about EMRs, typically that they’re not spending enough face-to-face time with the patient and most of their time is face to computer,” Alashari says. “But when you look at how it worked with written charts, nurses and doctors spent a great deal of time looking for the chart, waiting for someone else to finish working with the chart, and figuring out where someone put it down last.”
In addition to how an EMR makes far more information available then a paper chart, Alashari notes that most people type much faster than it would take to write the same information.
“I don’t see why they’re saying that it’s so difficult,” he says. “Do we really want to go back to when you had to leave the patient’s room to find the chart, stand outside while you read it because infection control doesn’t want it near the patient, and spend time trying to understand the doctor’s handwriting? It’s really much better than it was before.”
DESIGN OF SYSTEM
The design of the system and how it is used in the hospital can have a significant influence on whether clinicians feel it is monopolizing their time, says JoHannah Monk, RN, senior delivery manager with the Buffalo, NY, office of CTG, a company that provides IT services to healthcare systems and other industries. If the EMR simply automates what was already a bad work flow, the electronic system can increase time demands rather than making the process more efficient, Monk says.
“The EMR offers many benefits, but there are still issues that will dictate how much time your nurses spend with it. Where is the computer? Where are the meds? What are your staffing levels?” she says. “Do you have a work flow process that optimizes the nurse’s time, or are you blaming the EMR for a process that also would be problematic without the EMR?”
Monk agrees with Alashari that, whatever the documentation requirements, entering data in an electronic record will always be faster than writing by hand. Some nurses also might not realize how EMRs save time, she says. For example, nurses new to the field might not appreciate how much time used to be consumed by tasks such as trying to reach a doctor because a drug order was illegible.
However, Monk also cautions that the promises of increased efficiency can tempt administrators to lower the nurse-to-patient ratio. That change can create difficulties that are blamed on the EMR when the real problem is staffing.
If nurses are complaining about the time required by an EMR, Dreher suggests that risk managers develop a task force to address the EMR’s threat to patient safety and work with IT, nursing, and physicians to find solutions
“The patient is not at the center of the care model anymore. That’s the computer’s position now,” Dreher says. “A lot of the physicians and nurses I know are just at the end of their rope.”
SOURCES:
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Akram Alashari, MD, General Surgery, Surgical Critical Care, and Trauma, Grand Strand Regional Medical Center, Myrtle Beach, SC. Telephone: (407) 617-4795. Email: [email protected].
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Teri Dreher, RN, CCRN, iRNPA, Owner and CEO, North Shore Patient Advocates, Chicago. Telephone: (312) 788-2640. Email: [email protected].
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JoHannah Monk, RN, Senior Delivery Manager, CTG, Buffalo, NY. Telephone: (800) 992-5350.
