Electronic Medical Records: A Nursing Perspective from the Front Lines

Lisa Reichard, RN, Director of Business Development
April 18, 2010

There I was, both amazed and intrigued. After 10 years in the corporate world, I returned to the hospital setting for a Registered Nurse (RN) refresher. Motivated and ready to learn the latest patient-care technology, I found myself immersed in a whole new world. There was no charting by hand, no deciphering of hand-written physician orders flagged with page separators, and long-hand medication administration records were a thing of the past. No longer would I have to ask a peer "What does this say?" when I could not read illegible handwriting. And the "silos of charting" where nurses and physicians used to chart in separate areas - sometimes creating duplication and disconnected charting - were nonexistent.

My assignment consisted of a 13-week clinical at a 240-bed hospital in the Atlanta area, working both eight-hour and 12-hours shifts on a patient-care unit that provided inpatient, post-operative care. The unit had implemented its EMR system approximately one year prior, and it spanned all patient care areas but had not been implemented in the Emergency Room or Operating Room. Physicians, nurses, therapists, pharmacists and dietitians were all using the tool. The hospital's best practices and policies were incorporated into the EMR customization, as well as specific post-operative patient-care indicators for the unit.

CPOE was being utilized. Closed loop medication administration implementation was complete in all of the patient care service areas. The eMAR and bar coding were integrated with CPOE and pharmacy department, resulting in one point of care for medication administration.

The system interface was easy to use and navigation was intelligently developed. Had to learn the patient assessment indicators, pain scales and safety scales. On a post-operative unit, patient conditions can change rapidly and there were ample clinical customization indicators to document a full patient picture and the variations that can occur. Key phrases about the patient assessment were helpful cues incorporated into the EMR. Clinical best-practice guidelines based on the patient's symptoms and active diagnoses were incorporated throughout the EMR as well. It was great to find patient-care plans, and critical pathways were now components of the EMR and could be viewed across disciplines.

Here are my observations from the EMR experience as a caregiver from the front lines:

A challenge to user adoption was the fact that in an acute hospital setting, there are numerous PRN and part-time staff, plus temporary residents constantly rotating through the patient care areas.
Physician engagement and collaboration regarding the CPOE aspect of the EMR was very positive. They took ownership of the unit-specific standing orders they had developed and complied with CPOE guidelines.
Nurses appeared as a rule to be more proficient than physicians with the charting aspect of the EMR, which makes sense given that they are more frequent users.
Found it much easier to chart for a 12-hour shift than the shorter eight-hour shift. The EMR charting just seemed to flow more naturally with the longer shifts.
Found the closed-loop medication aspect to be outstanding with a positive impact on patient safety.
It was helpful to remind physicians during patient rounds to place orders for any needed x-rays, medications and therapy orders, should it be time to renew standing orders or place new orders.
Tech support and access were outstanding - even one year after implementation. They were readily available on all shifts, including weekends.
It was important to avoid the temptation to do any electronic charting in advance - i.e. patient's pain status, IV site assessment every 2 hours, etc.
It was important to avoid copying and pasting the previous shift's patient assessment on the EMR. Things may have changed, or their charting could be inaccurate. (I recently came across an article on just this topic entitled " Copy and Paste: A Remediable Hazard of Electronic Health Records" in the June 2009 issue of the American Journal of Medicine.)

Based on this experience, I would recommend Inclusion of the following in any EMR implementation plan for an acute care hospital setting:

Pre-implementation training with clinical area customization
Post-implementation training once further customization is complete
Require both written tests and live charting check-offs for each job description
Train-the-trainer with superusers assigned to each shift
IT support "walk around" to patient care areas each shift
IT help hotline available 24/7
Quarterly meetings with both physicians and clinical staff regarding user adoption and best practices. Should we add further diagnostic-specific indicators?
Talk with the physicians regularly. Can we streamline patient indicators or standardize CPOE based on specific patient population being treated on our unit? Is there adequate and consistent standardization with other patient care units?
Monthly newsletters emailed to all end-users featuring new EMR features and how to resolve frequently asked patient charting challenges. Post on the hospital website as well.