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Nursing vs. EMR: Win, Lose or Draw?

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In this article, the author explores some strategies for working well with electronic medical records EMRs, so that patient care remains our #1 priority.

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Nursing vs. EMR: Win, Lose or Draw?

As I sat on the couch in my patient's home, I could feel my computer drawing all the attention in its direction. Like some irresistible force, it seemed to lasso and pull away the family's eyes. I deliberately moved it to the side, setting it where I could still see it, but where it would not be a barrier between me and my patient and her family. I proceeded with the questions related to the admission, laying a hand gently on my patient's wrist, taking her pulse as we talked about her medical history.

Ah, the computer! Blessing or curse? Many electronic medical records (EMRs) are more in the latter category at this time, but over the years, they should continue to evolve so that they look more like they were destined to be: easy connectors and infallible memory banks. Yes, they are here to stay. Complaining and arguing and fighting against them does all of us a disservice. Instead of railing against what will truly become wonderful progress in the field of medicine, let us as nurses find ways to make computers assume their correct place in the nurse/patient relationship: as tools to be mastered, servants to the job at hand.

For those who knew nursing before the advent of computer, fear of change can be a destructive force, holding us back from rising to new challenges. But for all of us, the shear volume of documentation in the medical world can distract us from the centrality of the relationship with the patient- our most valuable work and truly the essence of nursing. Whether in an outpatient setting, doctor's office or hospital, we all currently work with computers or will in the near future. When we become completely comfortable and proficient with our EMRs, then the computer assumes its rightful place in the nurse/patient relationship-one more piece in our patient care puzzle. With fluency and complete ease of use, the program ceases to be master and becomes servant, sliding away from the part of our mind that triggers stress and into the more automatic response area-a chore to be done. But first, we must jump over the hurdles that keep us from settling in to learn it well.

As we use EMRs, the question becomes, how do we maintain our ability to be compassionate nurses while also keeping in step with the required documentation? How do we gracefully marry our professionalism with our humanity? Gone forever is the nurse in the white cap and starched uniform (no nostalgia here for that!), but we can all feel the danger posed by these little lighted boxes that we use all day, every day, demanding machines that require inordinate amounts of careful attention. Even if the old ways are gone, how can we continue to adapt well, nurturing our relationships with our patients while also documenting?

Here are some possible tips to consider. Feel free to add more of your own or comment on what works well for you:

Connection Counts

When possible, begin and end your encounter with a contact with the patient. In hospice, I like to try to shake hands and learn names and relationships. This opens the door to questions and sets the stage for open communication. Even if the patient is unresponsive, I feel it is important to say their name, maybe touch their shoulder, and let them know that I will be talking with their family for a time and asking some questions.

Set Up For Success

Be deliberate about how you position your machine. Don't let it take center stage. Try to angle your body toward the patient. When talking or listening, take your hands off the machine and try to assume a receptive posture (uncrossed legs and arms, palms open and turned up, if possible).

Save It

With some EMRs, it is possible to make notes and return to the screen to flesh out details later. If not, explain that you are going to type in some details before you turn to face the screen again.

Listen Well

Don't let the computer become the patient. As competent professionals, let's keep our eyes focused on what matters. Let's listen carefully to our patient's story. Let's not forego the gentle touch on the hand, the cool cloth to the fevered brow, the extra warm blanket, the ice chips on the parched lips.

Stay Positive

Working together to cultivate a positive attitude about the EMR and what it has the potential to do for us in medicine can pay off big dividends. Sometimes our default setting is called "complain," but we all know that this does little to help us move along constructively toward our goal: outstanding care for each and every patient with fewer mistakes and better communication. Some EMRs are definitely better than others, but all have pluses and minuses. Finding ways to work around the negatives can help us all get through these years of adjustment.

As the visit closed, I pushed the lid down on the computer and slid it into its bag before turning back to the patient to answer a final question about our scheduled return. I squeezed her hand and told her how much I appreciated this opportunity to talk with her and to get to know her and her family, closing the visit with a decidedly human touch.

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Joy has been a nurse for 35 years, practicing in a variety of settings. Currently, she is a Faith Community Nurse. She enjoys her grandchildren, cooking for crowds and taking long walks.

14 Likes, 4 Followers, 81 Articles, 144,544 Visitors, and 358 Posts.

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I loved the Computer system at the hospital where I worked. I always hated writing and trying to read others written notes. Just as I retired a new more complex system was put into use. The doctors orders were input by the physicians and that alone was a major safety issue the new system offered our patients.

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EMR is going to be started at our hospital soon. We are worried about the stability of the system and loss of data. Time taken to type is longer than writing. Worried data will be lost as there is no auto save.

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HIPPA laws will protect the hospital from data loss but not from time lost! But it will get better and faster as everyone gets used to the new system. I wish you well as you go through the transition. Joy

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As you noted, computers have a clear advantage when it comes to legibility and accessibility to all. All EMRs have pluses and minuses. I hope the problems you observed get worked out. Joy

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I've gone from NO computers to EMR's now. I know that the computers aren't going away, but honestly, it's SO much quicker to open a chart to find something you need........

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I've gone from NO computers to EMR's now. I know that the computers aren't going away, but honestly, it's SO much quicker to open a chart to find something you need........

I'm chuckling to myself because I, too, remember the NO computer days. But after more thought I also remember frustrations (and mistakes) trying to make out each other's handwriting, looking "everywhere" for the chart, searching for a specific lab report that is not where it is supposed to be and --don't forget the lovely care plan cardex, transferring orders by hand, etc. etc. Yep, it was different. Quicker? Not sure. What are some things that you remember? Things you miss and things you don't miss?

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I've gone from NO computers to EMR's now. I know that the computers aren't going away, but honestly, it's SO much quicker to open a chart to find something you need........

Using a paper chart is good and there are some things you can only easily do with a written chart... that being said, when you're dealing with a physical chart, one of the problems with it is that someone else can be using it when you need to. This causes quite the issue when you have to do something in a very timely manner and chart it and the chart is not available to you. When you have a physical chart, often you get very used to knowing exactly where to look in the chart for data that you need.

With an EMR system, if you know where to look, the data is there. This is no different than a paper physical chart system but you do have to know where to look. One of the other advantages of an EMR system is that multiple people can be working in the same file at the same time so that nothing gets misplaced inadvertently. Probably a bigger advantage of an EMR system is that you know who accessed the chart at any time. You cannot do this with a paper chart.

As far as speed of data entry, once you know how to do the entries as needed it actually gets to be fairly quick. I currently work with an EMR system and I can generally go through the entire assessment portion in less than 2 minutes. Part of this is that we chart by exception, but, I also touch upon every system. The one thing that I do not like about a CBE system is that if everything is considered "normal" there would be nothing in the chart. This is why touch upon every system.

As far as typing goes, I can type at least as fast as I can write but I can also dictate faster than I can type, however sometimes it is just simply easier for me to just type what I want to say just because occasionally the computer may misunderstand what I'm trying to say. Currently I'm using Dragon NaturallySpeaking and our physicians also use the radical version of that same system for their dictation and occasionally the system does not quite understand what you are saying so it inserts something that you don't quite want to put in there but if you read the sentence "phonetically" then you can usually understand exactly what the point is trying to be made.

Probably the most difficult part of learning to dictate to a computer is that you have to really think about what you want to say long before you say it. This is because the computer uses context to help determine what want to write. When you think about everything that you want to say as a series of paragraphs or sentences as opposed to a series of phrases, the computer then figures out what you want to say and usually does a fairly decent job doing it.

If we were to have to do dictation in the EMR system, I suspect that most floors would become a very noisy place during certain parts of the day just because a whole bunch of nurses would be talking to themselves… One of the other issues with dictation is that you do have to go back through and proofread what was written, I have done exactly that during this particular session simply because I needed to make sure that my thoughts were exactly transcribed as I had spoken.

Computers and EMR systems are not going away and probably will not for a very long time, that is until someone figures out a better way to do this. There also will not be a wholesale abandonment of paper system simply because at times the EMR system will be unavailable. This could be for upgrades, computer crashes, network crashes, and the like. All that being said, most nurses are going to need to at least tolerate how to deal with an EMR system because that is what's coming down the pike for pretty much everyone. It may not be faster for you, fast for me, but I guarantee you that I will be able to read exactly what you wrote. Good luck reading what I wrote, especially if I did it in cursive!

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Using a paper chart is good and there are some things you can only easily do with a written chart... that being said, when you're dealing with a physical chart, one of the problems with it is that someone else can be using it when you need to. This causes quite the issue when you have to do something in a very timely manner and chart it and the chart is not available to you. When you have a physical chart, often you get very used to knowing exactly where to look in the chart for data that you need.

With an EMR system, if you know where to look, the data is there. This is no different than a paper physical chart system but you do have to know where to look. One of the other advantages of an EMR system is that multiple people can be working in the same file at the same time so that nothing gets misplaced inadvertently. Probably a bigger advantage of an EMR system is that you know who accessed the chart at any time. You cannot do this with a paper chart.

As far as speed of data entry, once you know how to do the entries as needed it actually gets to be fairly quick. I currently work with an EMR system and I can generally go through the entire assessment portion in less than 2 minutes. Part of this is that we chart by exception, but, I also touch upon every system. The one thing that I do not like about a CBE system is that if everything is considered "normal" there would be nothing in the chart. This is why touch upon every system.

As far as typing goes, I can type at least as fast as I can write but I can also dictate faster than I can type, however sometimes it is just simply easier for me to just type what I want to say just because occasionally the computer may misunderstand what I'm trying to say. Currently I'm using Dragon NaturallySpeaking and our physicians also use the radical version of that same system for their dictation and occasionally the system does not quite understand what you are saying so it inserts something that you don't quite want to put in there but if you read the sentence "phonetically" then you can usually understand exactly what the point is trying to be made.

Probably the most difficult part of learning to dictate to a computer is that you have to really think about what you want to say long before you say it. This is because the computer uses context to help determine what want to write. When you think about everything that you want to say as a series of paragraphs or sentences as opposed to a series of phrases, the computer then figures out what you want to say and usually does a fairly decent job doing it.

If we were to have to do dictation in the EMR system, I suspect that most floors would become a very noisy place during certain parts of the day just because a whole bunch of nurses would be talking to themselves… One of the other issues with dictation is that you do have to go back through and proofread what was written, I have done exactly that during this particular session simply because I needed to make sure that my thoughts were exactly transcribed as I had spoken.

Computers and EMR systems are not going away and probably will not for a very long time, that is until someone figures out a better way to do this. There also will not be a wholesale abandonment of paper system simply because at times the EMR system will be unavailable. This could be for upgrades, computer crashes, network crashes, and the like. All that being said, most nurses are going to need to at least tolerate how to deal with an EMR system because that is what's coming down the pike for pretty much everyone. It may not be faster for you, fast for me, but I guarantee you that I will be able to read exactly what you wrote. Good luck reading what I wrote, especially if I did it in cursive!

Thanks so much for sharing your insights --especially on the DragonNaturallySpeaking system. It was quite interesting to understand a little more about that! Joy

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One of the problems I have with EMRs, and computerization in general, is that it enables the Powers That Be to count things that they weren't able to count before. This was my experience when I worked in business as well and it's not always a good thing. The Bean Counters are able to track things on such a minute level and they nit pick on things that would be better left alone.

Over all, I like the ability to chart electronically, but the system we have is not user friendly. It does not flow. There are too many clicks. In a previous career, I took some programming classes and they used to emphasize "elegant design." The programs I have used get the job done, I suppose, but they are frustration to use too much of the time.

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One of the problems I have with EMRs, and computerization in general, is that it enables the Powers That Be to count things that they weren't able to count before. This was my experience when I worked in business as well and it's not always a good thing. The Bean Counters are able to track things on such a minute level and they nit pick on things that would be better left alone.

Over all, I like the ability to chart electronically, but the system we have is not user friendly. It does not flow. There are too many clicks. In a previous career, I took some programming classes and they used to emphasize "elegant design." The programs I have used get the job done, I suppose, but they are frustration to use too much of the time.

You make some excellent points here about the drawbacks--even hazards!--of EMRs when it comes to majoring on the minors. I feel your frustration as we spend way too much time on things that really don't seem to matter in the grand scheme of attentive patient care. I also hear you and second your comment that many current day EMR's are far from "elegant." I have experience with one that is elegant, stream-lined--all you would want an EMR to be, but it is in a small local doc's office and not a major player in the EMR world. My hope is that as the years go by, EMRs will live up to their promise of bringing better quality and safety not just better numbers. Thank you for writing. Joy

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I never bring the computer with to a new admission. I bring a piece of paper and my favorite pen. I close the door,pull up a chair, sit next to them, and open the communication. I have all the questions memorized for the admission profile. On average I spend at least 30min more if needed just talking, listening and and assessing. So far it has not failed me in the building of a therapeutic relationship.

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