Keeping the Focus on the Patient and Their EHR: A Nurse’s Perspective

Sarah Romain, RN

As a bedside nurse I had several objectives for every shift. First: Provide safe and excellent care for my patients. I aspired to make a connection with each patient and use our relationship to gain insight into their needs, as well as to help them understand their health. Second: Document accurately and get out on time. No matter how busy the shift was, the warnings of my mentors haunted me: If you don’t document it, it didn’t happen. I was often much more successful at attaining my first objective. I frequently found myself documenting well after my shift was over, with resentment building for the redundancies that came with documenting in the Electronic Health Record (EHR).

Throughout my career as a nurse, I have experienced the benefits and challenges that the EHR presents while caring for patients. At times, it functioned as intended: to improve safety, quality, and communication. (1) However, patient care is nuanced and individualized, so it did not always align with the interface of the EHR, which caused unnecessary frustration and distraction. My cognitive focus was pulled in different directions, one with a focus on the patient, and the other on the demands of the EHR. (2)

In the past decade, EHRs have been widely implemented with goals to improve quality, safety, and communication across healthcare systems.(1) With mobile computers always available and computer stations built into the bedside of patients’ rooms, I came to rely on always having the EHR available at my fingertips. Safety features assisted in the prevention of medication errors, as the EHR required verification of the correct dosage and route for every medication administered. Data could be entered and accessed in real time, which allowed me to multitask patient care and documentation. This was a great benefit for my professional practice and patients, as I could work efficiently to find medical history, notes from providers, trend lab values, and make decisions based on many data points. I was able to be an effective advocate for my patients by using the communication tools built into the EHR, which allowed me to alert my healthcare team to problems and ask questions while staying with my patient. The ability to share critical information across many users in real time helped reduce delays in decision-making and allowed the multidisciplinary team access to the same information, no matter their location.

Despite the many benefits of the EHR, there are pitfalls as well. With so much information available in the EHR, the patient is at risk of being reduced to a collection of information. There is a value in physical assessment, knowing the patient, and trusting one’s instinct. (3, 4) I often observed overstretched and overwhelmed physicians who didn’t always come to see their patients, instead relying on the medical record to assess the situation. This created incomplete context for the patient’s situation and misinformed direction for their care. This forced me to value my own assessment and judgment, and to trust that there is some information that can’t be transcribed perfectly into a medical record. At times I felt at odds with the information in the EHR, insisting that providers come in person to assess the patient, even if only based on my intuition that something “just didn’t look right.” Spending time with a patient builds a personal and intimate knowledge that nurses use to inform care. What concerned me about a heavy reliance on the EHR to make decisions is that there was no standard form that could capture what that knowledge provided. The more time spent documenting, the less time there was to build upon these relationships which informed my intuition about them. (3)

The intangible dissatisfaction and frustration I’ve experienced have been described as the unintended consequence of a loss of cognitive focus. (2) Navigating the EHR to find the necessary information was not always intuitive, and synthesizing it all on a screen was not easy. Focus was also lost when “to do” items would pop up, with mandatory forms to complete and alerts that tasks were not yet documented. At times, this split my attention between the patient in front of me and their data next to me. The demands of the EHR often felt more like an obstacle than a tool while striving to build authentic and healing relationships with my patients.

A few years ago, I left my role as a bedside nurse to work as a research nurse in clinical trials. This position introduced me to new ways to use the EHR, and I developed a profound appreciation for how the information is used to impact meaningful change in practice. The details of care are heavily examined and scrutinized at every level, from local researchers to (at times) federal agents. These data are so valuable, and it’s typically the nurses who contribute so much of it to the patient’s chart. The mantra of my mentors continues to ring in my ears, but now I add my own line to it when I speak to my fellow nurses: “Please, document it all. It matters.”

Sarah Romain, RN is a clinical research nurse at Baystate Medical Center and is earning a PhD in Nursing from the Tan Chingfen Graduate School of Nursing at UMass Chan Medical School.

References:

1. HealthIT.gov, 2014. EHR Incentives and Certification. http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives

2. Wisner, K., Lyndon, A., & Chesla, C. (2019). The electronic health record’s impact on nurses’ cognitive work: An integrative review. International Journal of Nursing Studies, 94, 74-84. https://doi.org/10.1016/j.ijnurstu.2019.03.003

3. Price, A., Zulkosky, K., White, K., & Pretz, J. (2017). Accuracy of intuition in clinical decision making among novice clinicians. Journal of advanced nursing, 73(5), 1147-1157. https://doi. org/10.1111/jan.13202

4. English, I. (1993). Intuition as a function of the expert nurse: a critique of Benner’s novice to expert model. Journal of advanced nursing, 18(3), 387-393. https://doi-org.umassmed.idm. oclc.org/10.1046/j.1365-2648.1993.18030387.x