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Do EHRs Push Nurses to Lie?

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EHRs can be great. But they are not perfect. While they convey facts very well, they often miss out on the bigger story behind the facts. Sometimes, nurses have to end up checking boxes that don't totally fit the situation. Is that lying? Share your thoughts!

by jeastridge jeastridge, BSN, RN (Trusted Brand)

Specializes in Faith Community Nurse (FCN).

Electronic Health Records (EHR) Are Not Perfect.

Do EHRs Push Nurses to Lie?

The nurse looked up to the wall where the digital clock from a bygone era registered 7:55. He felt the combination frustration and total despair rising up in his throat as he tried to record all of what he had done since 7 a.m. —ages ago now, it seemed. He clicked through the electronic health record (EHR) steadily trying to reproduce his day accurately through a series of clicks on boxes that didn’t at all fit the events.

Consciously slowing down so as not to make any accidental errors which could result in even more delays, he tried his best to find ways to use clicks to describe a narrative of a day gone bad: there was the patient that crashed, several that needed their pain medications adjusted, and, of course, the admission and the discharge. All of this activity resulted in literally thousands of clicks through well-worn screens of the now-familiar, but ever-cumbersome EHR.

Reality Doesn't Match Rosy Dream

The nurse remembered back not even 20 years ago when computer records held forth so much promise: they would be better, more efficient, and certainly involve fewer errors with record keeping. Reality simply didn’t seem to match the rosy dream. The electronic world has indeed brought forth a new era in medicine but along with it, some unpleasant side-effects that can make them a bitter pill to swallow.

How often do you find yourself clicking choices without matching what you really want to say?

The scenario above may sound all too familiar to today’s health professionals who work hard every day only to find themselves unable to accurately transcribe into an EHR what they have seen and done in a way that is easy for others to follow. Not only that, by “sort of” being able to click through choices without truly matching what they want to say, the nurse or other professional may find themselves in the uncomfortable position—and sometimes unethical position—of feeling like they might be telling a “sort of” lie. It is appalling to think about, and many would probably deny that it happens, but those in the field know all too well the feeling of not having the choices they need to click on within the EHR.

Practitioners are sometimes asked to populate templates that may include items they didn’t have time to thoroughly check, thereby creating a half-truth that leaves the conscientious nurse uneasy and unable to feel like he/she did a great job. By repeatedly subjecting ourselves to this need to click on or populate parameters that aren’t totally true, it is possible that eventually a certain numbness develops, taking excellence and pride right out the door with it. It is ironic that in the search for accuracy and perfection, modern electronic health records create a climate that fosters instead, more half-truths and whole lies.

Lots and Lots of Facts, But, Lousy Patient Story

Besides pushing nurses into difficult ethical territory, another unintended consequence of EHRs is their inability to tell a story well. They do a superb job of remembering facts—lots and lots of facts—but they do a lousy job of telling a good, solid, complete patient story. How many times do patients have to parade through the exact same questions over and over again? How many times does the story of their medical history get totally lost in the avalanche of clicks and the paper-work it produces? How many times does what happened yesterday with their pain or their constipation or their access line or their family member get lost into clicks many screens ago, and become, in practical terms, irretrievable? How many times do nurses find themselves asking the patients what happened to them since you last saw them? The puzzled looks from our patients should tell us something as they furrow their brows seeming to wonder, “Can I trust these people to care for me?” 

How many times do we tell families not to leave loved ones alone at our hospitals anymore because we can’t know for sure that one shift will have the ability to communicate with the other that Momma has dementia or that Daddy always gets dizzy after he takes a pain pill?  Our patients’ stories sometimes get swallowed whole by the EHR, making the daily chore of sharing their physical current events paradoxically much harder than it should be.

Lack of Cohesiveness and Communication Between EHR Systems

Our current system of EHRs is fractured and fragmented. While some individual systems are good, there is a lack of cohesiveness and communication between systems so that going from one doctor to another or one town to another poses a good deal of risk. A simple transfer from a hospital to a long term care facility can be fraught with danger for fragile patients. Poor information transfer can result in myriad health complications including medication errors, falls and re-hospitalization.

It is true that there are some outrageously good EMRs out there and despite the many problems, computers do keep accurate records of what we put in them; they know how to spell; they don’t have messy handwriting; they can scan a barcode like nobody’s business; they never get mixed up on a name. However, they do have a really hard time telling a good, accurate story, and sometimes in our quest for perfection and our great desire to eliminate even the remote possibility of a lawsuit, we ask our programmers to design EHRs that take us all to the edge of craziness, pushing professional nurses into a daily corner of half-truths or is it lies?

What has your experience been with EHRs?

Joy is an FCN. She has been a nurse for many years and enjoys writing about nursing issues. In her spare time, she loves a good long walk, cooking for a crowd (in non COVID times, of course!), and caring for her grandchildren.

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27 Comment(s)

Undercat, BSN, MSN, CRNA

Specializes in Retired. Has 41 years experience.

EMR's were created for the people who sell them .  Onerous demands put up on the staff to collect more data than we need is driving nurses and doctors out of the field and may be one part of the reasons that the suicide rates are up.

jeastridge, BSN, RN

Specializes in Faith Community Nurse (FCN).

5 minutes ago, Undercat said:

EMR's were created for the people who sell them .  Onerous demands put up on the staff to collect more data than we need is driving nurses and doctors out of the field and may be one part of the reasons that the suicide rates are up.

Stress levels are incredibly high. The resulting health and community effects are real but hard to measure. Thank you for your comment.

mmc51264, ADN, BSN, MSN, RN

Specializes in orthopedic; Informatics, diabetes. Has 9 years experience.

I was a brand new nurse and when I started my current job, I felt incompetent. I could never get done what my preceptor wanted. 6 months into my job, they switched over to EPIC. I felt like a new person. I guess I must be the exception, but I found that I had an affinity to the system and learned it quickly. 

Fast forward 7 years and I now have an MSN in Informatics, but have stayed on the floor to help new nurses or older ones who still struggle, become "fluent" in EPIC. 

I know that smaller systems may not purchase a program with all the bells and whistles, but I feel that I am able to do what I need, chart what I need, efficiently. I am on a committee that works on optimizing what we have. 

I am not sure what part of charting one does that is a "lie"  I am still able to write a quick SBAR-type note to address a crash, or a change in pain medications. 

I personally think that if people learned how to use the technology to their benefit, it would help, not hurt, and that is my mission .

mfdteacher, BSN

Specializes in ICU/ER. Has 40 years experience.

To clarify, I am a retired ICU/ER RN, thus an old fart!  I always preferred narrative charting simply because when asked to testify (a few cases over 40 years), I could look at my notes and recall the day so much better.  And I could use patient quotes as well.  I have worked with EHRs but none of the systems seemed to have the "right" check boxes and I would always end up using as much narrative charting as possible...which did not endear me to admin types.  One other advantage was being able to read other nurses and physicians notes and get a much better picture of the patient's care.  Just my two cents.

jeastridge, BSN, RN

Specializes in Faith Community Nurse (FCN).

49 minutes ago, mmc51264 said:

I was a brand new nurse and when I started my current job, I felt incompetent. I could never get done what my preceptor wanted. 6 months into my job, they switched over to EPIC. I felt like a new person. I guess I must be the exception, but I found that I had an affinity to the system and learned it quickly. 

Fast forward 7 years and I now have an MSN in Informatics, but have stayed on the floor to help new nurses or older ones who still struggle, become "fluent" in EPIC. 

I know that smaller systems may not purchase a program with all the bells and whistles, but I feel that I am able to do what I need, chart what I need, efficiently. I am on a committee that works on optimizing what we have. 

I am not sure what part of charting one does that is a "lie"  I am still able to write a quick SBAR-type note to address a crash, or a change in pain medications. 

I personally think that if people learned how to use the technology to their benefit, it would help, not hurt, and that is my mission .

Such a great comment! Thank you for your input and perspective. I love that you are working to make things better for others. Way to go! Joy

22 minutes ago, mfdteacher said:

To clarify, I am a retired ICU/ER RN, thus an old fart!  I always preferred narrative charting simply because when asked to testify (a few cases over 40 years), I could look at my notes and recall the day so much better.  And I could use patient quotes as well.  I have worked with EHRs but none of the systems seemed to have the "right" check boxes and I would always end up using as much narrative charting as possible...which did not endear me to admin types.  One other advantage was being able to read other nurses and physicians notes and get a much better picture of the patient's care.  Just my two cents.

Your 2cents are worth more than that! Thank you for sharing your view. Some EHRs are clearly better than others.

Allgood2016, LPN, LVN

Specializes in Pedi; Geriatrics; office; Pedi home care.. Has 46 years experience.

I am retired, now.  I am; and, was; considered "old school".  My last job was at a small assisted living center.   My notes (narritives in charts) on incidents there saved the company from a couple of law suits.    

I was taught (back in the 70s) that there was no such thing as overcharting on a patients condition.   Click the box charting without a good narrative is; to me;  a dangerous situation for not only the patient and nurse; but for the facility as well.

 

Ado Annie, ASN

Has 8 years experience.

Funny, I read this when I had a couple of minutes available because... the EHR was down. I had just completed 0400 vitals and couldn't enter them. Two patients requested narcotics. Labs had just been drawn.

One employer's adaptation of Epic left me feeling as if I had clicked about 50 times per patient per shift just to show that I understood every possible way this patient could fall and what I was doing about it. Great for protecting the facility in the event that there's a lawsuit over a fall. Maybe a good reminder of what to look for and what to think about and what to implement, but ... maybe overkill? I do sometimes feel that charting takes up time that could be spent actually caring for the patient. And at the busiest facility I often end up staying over an average of 45 minutes to finish my charting, often with a scenario like the one in your article: trying to reconstruct my day without lying. 

What about the clicks that your employer expects, such as hourly rounding? But in reality, you didn't see that patient for 2-3 hours because there was an emergency, or your patient said "while you're here, I'd better go to the bathroom" and that took 45 minutes (multiply this by your patient load and you can see how time gets away from you)?

I have a BS in Comp Sci, worked in the data field for many years. I get that narratives are hard to aggregate into reportable sets of data. But I also think we ask too much of a system, and of nurses, and of support staff, and that leads to "lying".

jeastridge, BSN, RN

Specializes in Faith Community Nurse (FCN).

25 minutes ago, Ado Annie said:

Funny, I read this when I had a couple of minutes available because... the EHR was down. I had just completed 0400 vitals and couldn't enter them. Two patients requested narcotics. Labs had just been drawn.

One employer's adaptation of Epic left me feeling as if I had clicked about 50 times per patient per shift just to show that I understood every possible way this patient could fall and what I was doing about it. Great for protecting the facility in the event that there's a lawsuit over a fall. Maybe a good reminder of what to look for and what to think about and what to implement, but ... maybe overkill? I do sometimes feel that charting takes up time that could be spent actually caring for the patient. And at the busiest facility I often end up staying over an average of 45 minutes to finish my charting, often with a scenario like the one in your article: trying to reconstruct my day without lying. 

What about the clicks that your employer expects, such as hourly rounding? But in reality, you didn't see that patient for 2-3 hours because there was an emergency, or your patient said "while you're here, I'd better go to the bathroom" and that took 45 minutes (multiply this by your patient load and you can see how time gets away from you)?

I have a BS in Comp Sci, worked in the data field for many years. I get that narratives are hard to aggregate into reportable sets of data. But I also think we ask too much of a system, and of nurses, and of support staff, and that leads to "lying".

Thank you for your comment. It seems we lack balance in our EHRs? Or maybe, as another reader pointed out, the EHRs are designed for someone besides patient care providers? It gives us lots to think about. Joy

OUxPhys, BSN, RN

Specializes in Cardiology. Has 4 years experience.

EHR's don't have to be bad but the documentation requirements made by upper administration are beginning to be too much. I find at my current job I am often double charting.....alot. 

RN-to- BSN, ADN, RN

Specializes in SCRN. Has 7 years experience.

Excuse me, should there be a PM inserted after 07:55 or change to 19:55? Otherwise, it seems like only 55 minutes elapsed from the 0700 AM.

If the time is now 19:55, and the nurse in the example is THIS much behind, I am doubting the time management skills.

And no, I do not feel like lying entering the information into EHR. Boxes might need to be clicked, but the comments section is still there to clarify.

Thank you!

Edited by RN-to- BSN

jeastridge, BSN, RN

Specializes in Faith Community Nurse (FCN).

33 minutes ago, RN-to- BSN said:

Excuse me, should there be a PM inserted after 07:55 or change to 19:55? Otherwise, it seems like only 55 minutes elapsed from the 0700 AM.

If the time is now 19:55, and the nurse in the example is THIS much behind, I am doubting the time management skills.

And no, I do not feel like lying entering the information into EHR. Boxes might need to be clicked, but the comments section is still there to clarify.

Thank you!

You are right. I should have made it military time to be clear. Thanks! Joy

1 hour ago, OUxPhys said:

EHR's don't have to be bad but the documentation requirements made by upper administration are beginning to be too much. I find at my current job I am often double charting.....alot. 

Maybe, over time, administration and those that create the EHRs will begin to make them more efficient. We hope. Joy

Daisy4RN

Specializes in Travel, Home Health, Med-Surg. Has 20 years experience.

There were no EHRs when I started nursing. Everything was hand written including the care plan. We eventually got care plans (on paper) that had boxes to check and that made it easier.  We were also hopeful that the EHR would save time but of course it did not. Many pt issues needed further clarification than checked boxes so it took longer bc we had to do both. The MARS were just a hot mess, not allowed to change times so needed to call pharmacy which was very time consuming (among other problems). EHRs were not created for the ease of staff charting or to improve pt care (even though we were told so) but for billing, and for admin to check charting for all the ridiculous things they have added over the years which of course can lead to nurses and others charting things that didn't happen (like hourly rounding etc).

jeastridge, BSN, RN

Specializes in Faith Community Nurse (FCN).

19 hours ago, Daisy4RN said:

There were no EHRs when I started nursing. Everything was hand written including the care plan. We eventually got care plans (on paper) that had boxes to check and that made it easier.  We were also hopeful that the EHR would save time but of course it did not. Many pt issues needed further clarification than checked boxes so it took longer bc we had to do both. The MARS were just a hot mess, not allowed to change times so needed to call pharmacy which was very time consuming (among other problems). EHRs were not created for the ease of staff charting or to improve pt care (even though we were told so) but for billing, and for admin to check charting for all the ridiculous things they have added over the years which of course can lead to nurses and others charting things that didn't happen (like hourly rounding etc).

Problems with EHRs persist. I hope that at some point EHRs will become more practitioner-friendly and more patient care centered. Again, there are great EHRs out there--but they are not all great. Joy

On our system, each main area has a Note: entry at the end.  I have seen nurses use these entries to virtually recreate a narrative chart.  Personally, I have shortened my narrative quite a lot to coincide with the "less is less" attitude that goes along with electronic charting.  And all the time wasted going back and back and back again even, to insure no slips get entered.  Don't start me on that.

CKPM2RN, ASN, EMT-P

Specializes in Emergency/Med-Tele. Has 3 years experience.

On 9/10/2020 at 6:05 AM, Ado Annie said:

...just to show that I understood every possible way this patient could fall and what I was doing about it.  

And the Braden scale, every shift, every day even if it is not slightly applicable to that patient.

I do sometimes feel that charting takes up time that could be spent actually caring for the patient. And at the busiest facility I often end up staying over an average of 45 minutes to finish my charting, often with a scenario like the one in your article: trying to reconstruct my day without lying. 

If I could write a note about what I actually did, it would take less time than the drop down flowsheets in EPIC. To make the drop downs make sense I have to add comments on several, imagine if I just wrote the comments! So much faster.

What about the clicks that your employer expects, such as hourly rounding? But in reality, you didn't see that patient for 2-3 hours because there was an emergency, or your patient said "while you're here, I'd better go to the bathroom" and that took 45 minutes (multiply this by your patient load and you can see how time gets away from you)?

Yeah, hourly rounding...about that....

But I also think we ask too much of a system, and of nurses, and of support staff, and that leads to "lying".

Lying by omission, by not painting the true picture. 

 

Kitiger, RN

Specializes in Private Duty Pediatrics. Has 42 years experience.

The MARs we have to use are so time-consuming. To chart a medication, I have to click on "Medications", wait for it to load, locate the med I need and click on that, wait for it to load, click on "Adm" to get to a list of when that med was last given, wait for it to load, then click on the tab that opens up the page I need to chart that I gave the med, wait for it to load, click that I gave the med, then two clicks to get back to the main medication list, then start over, to chart the next medication.

Who has time for that?

(And, yes, I'm old school, graduated in `79).

jeastridge, BSN, RN

Specializes in Faith Community Nurse (FCN).

7 hours ago, Kitiger said:

The MARs we have to use are so time-consuming. To chart a medication, I have to click on "Medications", wait for it to load, locate the med I need and click on that, wait for it to load, click on "Adm" to get to a list of when that med was last given, wait for it to load, then click on the tab that opens up the page I need to chart that I gave the med, wait for it to load, click that I gave the med, then two clicks to get back to the main medication list, then start over, to chart the next medication.

Who has time for that?

(And, yes, I'm old school, graduated in `79).

You make a valid point. It seems like EHR programmers could make this work faster. And being "old school" you may also have experienced a variety of ways of doing the same process...Thank you for your comment.