Roundtable: Include Nurses in the Conversation to Reduce EHR Burden

HEALTHTECH: Can you give an overview of the study and your findings?

NGUYEN: My team wanted to look at where the progress on research has been for nurse burnout and EHR use. We also wanted to see what recommendations nurses have offered as opposed to recommendations provided by physicians, healthcare administrators or other non-nurses. We reviewed over 4,500 articles and found only 12 papers that could give us more information on this.

There were many more studies examining physician burnout and EHRs than nurse burnout. Even so, we were able to uncover a few themes. We found nurses’ recommendations focused on a few key areas: investing in additional computer workstations, offering tailored EHR training, getting nurses’ feedback or direct involvement with helping the EHR team align their EHR workflows to match their nursing work, and developing screen designs that could summarize concisely a wealth of patient data to minimize clicking and searching.

FELDMAN: I am encouraged by how many studies I am starting to see around nurse burnout and wellness specifically, and I think we will see a lot more in 18 to 24 months after the height of the pandemic.

Nurses really are the front line of the bedside. They are the people who transmit data and translate it into actionable information, frequently without the physician at the bedside. That’s what’s needed, and they’re really good at it.

HEALTHTECH: How is the well-being of nurses impacted by EHR use?

NGUYEN: Many clinicians went to school to make a difference in patients’ lives. That often means having direct, face-to-face patient interactions. What we’re seeing here is a lot of folks going through those training pathways only to go into a working environment that has them spend more time with the EHR than they really want to. If I’m making a nurse do more typing than bedside care, that’s probably going to have a long-term effect by creating this general disdain toward the EHR.

Recognizing that the EHR is a tool to facilitate patient care rather than an end to that is probably going to be key to mitigating well-being issues among nurses.

MERLO: The EHR has resulted in siloing the work effort. Physicians might go back to their offices while nurses have access to a workstation on wheels or a computer at a nurse’s station. They’re doing their work independently and isolated now in a way that’s very different from how it occurred when you had paper charts sitting in a cart in the nurse’s station. There were opportunities to ask a quick question when the physician or pharmacist came in to check something from the chart. Now you might not even be in the same building when the documentation is occurring.

The additional effort of having to call, email or text the other members of the healthcare team adds this extra burden of time and effort on top of waiting for a response. However, there are definite benefits as well, because more information is available quickly. You can get your test results right away; you don't have to flip through pages. It can be easier to find and share information across systems or across buildings in a way that you couldn’t when it required faxing.

HEALTHTECH: What are some ways to mitigate the EHR and documentation burden?

NGUYEN: The EHR and documentation burden are related issues, but they require distinct solutions because of their underpinnings. The documentation burden stems from regulations and policies that can be set by the federal government or Centers for Medicare and Medicaid Services, but it can also be set by private insurers. Over time, the ease of being able to collect data has created an environment where we're asking for more.

Clinicians are documenting a huge range of data to satisfy different insurers. We need to harmonize those quality measures. Can we consolidate them down to a core group so that we can reduce the number of things that clinicians need to document? We’re also seeing ways for insurers to utilize interoperability to pull information out of the EHRs themselves.

As for the EHR burden, we know that if you don’t design screens well or adhere to basic user experience principles, you create a situation that fosters patient safety issues. We know green usually means something good is happening, red usually means something bad. If you reverse those color codes, you’re probably not going to get a very good patient care outcome.

Whether we like it or not, the EHR has become an integral part of providing healthcare in the U.S. Not having a basic comfort level with general computer and EHR skills downstream could prove to be a barrier that may need to be integrated and emphasized more in the curriculum.

DISCOVER: Learn how to bridge the gap between nurses and IT teams.

MERLO: It’s important to be more intentional about what information is visible and what information is extraneous. For example, if you have an 80-item screening questionnaire and 78 of the items are not a problem, does the physician or nurse need to scan through all 80 items? Or, could the system pop up and say, “These are the two items of concern.” That would help everyone focus on the clinically relevant information and save some time and effort.

In terms of documentation burden, we talk a lot about helping the clinicians operate at what's called the top of their license. There are skills and knowledge that they uniquely possess, and typing is not one of them. If we can utilize more voice input, scribes, medical assistants or others who can do more of the clerical burden in terms of interacting with the EHR, then when the patient is face to face with the nurse or the doctor, they’re nursing and practicing medicine instead of spending their time on data entry.

FELDMAN: Some of what’s been missing in current EHR systems is a level of intelligence and voice recognition. I think the first EHR vendor to include a great user experience, a highly intelligent system and excellent voice recognition is really going to win. This is a sector of healthcare that is ripe for disruptive innovation.

HEALTHTECH: How can healthcare organizations bridge the gap between nurses and IT teams to ensure a better workflow?

NGUYEN: Most large organizations would generally have a dedicated team whose only purpose is to manage the EHR. That can include troubleshooting or creating new features for that specific organization’s needs.

Having that group engaged with its clinical staff can give an idea of what the local needs are at that healthcare organization. And in turn, that can translate to some of the more technical needs and specifications that their clinicians need to support their own workloads and communicate to the EHR headquarters. The developers can then push it out to all the organizations that use their product.

MERLO: You don’t know what you don’t know, and so if IT teams are not including the relevant stakeholders when having these discussions, they’re missing key information.

When looking at the day-to-day experience of a bedside nurse, for example, there are many little interactions with the EHR that all add up. Every time you add an extra click for one task, you need to multiply that by the dozens of times that they must do that task over the course of a day. It very quickly becomes what we refer to as pebbles in your shoe, little things that make your day a bit more unpleasant.

Including the perspective of the people who are there on the front line to point these things out might not seem like a big deal if you’re coming from the IT side, but it’s vital for the general health, well-being and burnout prevention of our front-line clinicians.

On the flip side, nurses may not know all the EHR’s capabilities. They may not recognize that something’s an easy fix because they’re not trained to be an EHR developer. Having everyone sit down together and get everyone’s perspective is really going to be the solution to make the EHR work for the whole team.