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!
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?
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).
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.
...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.
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.
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.
Worse yet are the systems with “hard stops” built in, so you have to click a box and type a password if you clicked that box. That’s a fine setting if it happens once or twice a day, but typing 50 or a hundred *extra* passwords doesn’t increase patient safety.
much like putting excessive alarms out there, adding duplicate checkboxes and “password verification” - and multiple places where things like blood pressure *must* be entered again and again focuses the care giver on the computer and not on the patient.
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).
Heh. Our MARs are still separate on paper. Thank heavens for however long that situation lasts.
This all reminds me of my impressions of the behavior of a specialist I saw who kept his eyes glued to whatever he was typing on his laptop. He barely approached me for the most cursory of actual physical exams. All that charting must have contained a lot of fibbing. This was a long time ago, but I distinctly remember forming a negative impression of electronic documentation from this single instance.
Worse yet are the systems with “hard stops” built in, so you have to click a box and type a password if you clicked that box. That’s a fine setting if it happens once or twice a day, but typing 50 or a hundred *extra* passwords doesn’t increase patient safety.
much like putting excessive alarms out there, adding duplicate checkboxes and “password verification” - and multiple places where things like blood pressure *must* be entered again and again focuses the care giver on the computer and not on the patient.
So very frustrating. Programmers may mean well but the added layers of "security" may indeed cause poorer care. Thank you for your comment.
Daisy4RN
2,238 Posts
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).