1. Fields, Willa DNSc, RN

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Communication: the act or process of using words, sounds, signs, or behaviors to express or exchange information or to express your ideas, thoughts, feelings, etc., to someone else; a message that's given to someone; a letter, telephone call, etc.1

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Electronic health record (EHR): a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.2


Nurses continuously communicate with other clinicians, patients, and families. And this communication takes many forms: in synchronous, face-to-face, verbal communication with patients and their families during care delivery and in synchronous and asynchronous communication during the coordination of patient care with other clinicians. We use the telephone, paper, and a variety of technologies as we exchange information with others. Communication is central to our work of providing and coordinating patient care.


Yet, communication doesn't always result in positive patient care or outcomes. For example, in the sentinel events reported to The Joint Commission, communication has consistently been identified as a root cause and failure point that compromises patient safety.3 Since 2003, The Joint Commission has identified National Patient Safety Goals (NPSGs) that are based on issues identified from reported sentinel events and root cause analyses, and communication has remained on the list of goals since its inception.4 EHRs are a tool we can use to improve our communication among clinicians.


Documentation vs. communication

Improved communication has been identified not only as an NPSG, but also as one of the main goals of health information technology (IT) adoption, including EHRs.5 If health IT is a tool that improves communication among clinicians, how can we maximize its use in communicating patient care data and information?


An excellent example of a communication failure and subsequent solution with an EHR is what happened at Texas Health with its Ebola patient. On September 30, 2014, the CDC confirmed that a man who had traveled from Liberia to Texas had the Ebola virus.6 Accounts of what happened appeared in the media.7 An ED nurse at Texas Health documented in the patient's EHR that he had a fever and recently returned from Africa. The patient was discharged, only to return to the hospital several days later, becoming the first person in the United States to be diagnosed with Ebola. He died on October 8, 2014.


In response, the U.S. House Energy and Commerce Committee, Subcommittee on Oversight and Investigations, held a hearing on October 16, 2014, to examine America's public health response to Ebola, including the events at Texas Health.8 A physician from Texas Health testified that they've made changes in their care processes and are utilizing their EHR functionality to help clinicians screen for Ebola and other infectious disease risk, and increase the visibility and communication of findings. An electronic screening tool for infectious disease risk now provides a single place to document screening results and allows for multiple views and alerts. Although the ED nurse had correctly documented her findings in the Ebola patient's EHR, the information wasn't easily accessible or visible. Documentation occurred, but not necessarily communication. By redesigning the information flow in the EHR, communication is enhanced.


Nurses improving information flow

Evidence of improved communication with EHRs has been reported in the professional literature. Nurses have reported that implementation of a computer-based nursing information system provided more information and improved their information processing.9 EHRs have demonstrated changed communication patterns among clinicians.10 Although there's less face time between physicians and nurses, when EHRs are implemented nurses report being more knowledgeable about their patients because of the ready access to patient data from all disciplines.11,12 Research results have also demonstrated improved communication across disciplines and care settings after implementation of EHRs.12-15 Although research has demonstrated improved communication and information flow with EHRs, they're often underutilized as a communication vehicle.16


As the Ebola example demonstrates, simply having nursing documentation in the EHR doesn't guarantee communication and information flow among clinicians. Although the nurse documented that the patient had a fever and had been in Africa, the information wasn't readily available to the physicians. Texas Health redesigned its Ebola and infectious disease screening tool and improved communication among clinicians. How can nurses help identify ways to improve communication in EHRs?


Getting nurses involved

Getting involved in the design, implementation, and optimization of EHRs helps ensure our patients receive the best care. As a first step, nurses can volunteer to be a super-user on your unit. As a super-user, the nurse receives additional EHR education and will be the "go to person" on the unit for EHR support. As nurses become more familiar with EHRs and health IT, they can identify areas for EHR optimization. No matter how good your system may be, EHRs are evolving. Who better than nurses to identify ways to make the system better and easier to use? Encourage your nurses to volunteer to participate in one of your organization's EHR committees or groups. Clinical nurse involvement is critical to optimize the design, information flow, and use of an EHR and other health IT.


EHRs aren't a replacement for synchronous voice-to-voice or face-to-face communication. They're an additional tool that we can use in our practice to convert documentation to a communication vehicle. We can optimize the value of patient information in EHRs through actively participating in their design, implementation, and optimization.


Sharing expertise

With nursing involvement in EHR design, we can better ensure that EHRs support patient care with information flow and improved communication of critical information. Nurses need to collaborate with technical staff in the development and testing of screen designs and information flow in EHRs. Nursing management must ensure time for clinical nurses to participate in this process. After EHRs have been implemented, it's equally important for nurses to provide constructive feedback on ways to improve functionality, information sharing, and communication capabilities. By utilizing nursing expertise in all of these areas, EHRs can be used not only to document care, but also to improve communication.




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