1. Hirsch, Audrey MS, RN

Article Content

Technology has changed the world, and health information technology (HIT) will continue to have an enormous impact on healthcare delivery processes and structures. Many hospitals use implementation and optimization of the electronic health record (EHR) as an opportunity to streamline, standardize, and improve care processes.1 To sustain these efforts, it is essential to design workflows to support the use of the valuable data contained in the EHR and mined from other technologies to promote care coordination, best practices, and quality improvement.


Frequently, critical care nurses are not fully invested in this work, leaving content development, workflow redesign, and innovation explorations to nurse informaticists and others. Unfortunately, this leaves nurses at a significant disadvantage. Nursing is now a multigenerational workforce and everyone needs to be fluent in the language of technology.



EHR documentation templates should support clinicians in their ability to reflect and think critically to develop individualized care plans.2 However, as EHRs become ubiquitous, some researchers have found that computers are not yet part of nurses' ongoing workflow; they are accessed periodically and nurses tend to chart in batches.3 Both the technology and access need to evolve in order to fully realize potential benefits and efficiencies, resulting in greater synthetization of electronic documentation. This means that nurses must view computers and HIT as essential components of care, rather than additional work.3


A landmark 2008 study found that nurses spent approximately 35% of their time documenting.4 A time and motion study in 2012 found very little difference in time spent documenting in an EHR versus on paper. This study noted that nurses spent an average of 19% of their time completing documentation, regardless of electronic charting usage, compared with all other categories of care. These findings suggest that integrated EHRs do not increase the time nurses spend documenting.5


Despite these findings, many nurses continue to believe that electronic documentation results in more time spent documenting and less time spent caring for patients.6 Nurse behaviors, bad design, and facility conditions may actually be to blame for this perception rather than the technology itself. These include:


* initial recording of data on temporary notes or by memory with the intention of transcribing the data into the EHR at a later point


* lack of comfort, competence, or confidence in electronic documentation


* too few devices to support bedside documentation7


* awkward placement of fixed or mobile bedside devices8


* ineffective documentation templates or content.



Nursing leadership should promote better time management and efficiency in electronic documentation by emphasizing real-time documentation at the bedside. The benefits of real-time documentation for critical care nurses include:


* time savings (making documentation a one-step process)


* increased time spent at the bedside


* improved interdisciplinary communication regarding patient status through real-time information made available to all team members


* increased collaborative workflows within the interdisciplinary team


* improvement in documentation accuracy (eliminates unreliable intermediary forms of documentation such as memory or handwritten notes)



Real-time documentation allows nursing data to become a significant contributor to the development of predictive analysis and automated indexes. A recent journal article validated the frequency and clinical validity of nursing assessment data.9 A literature search reiterated the need for electronic nursing decision support tools for predictive analysis and further extrapolated the need for adequate communication and escalation protocols to accompany such tools.10


A reduction in the overall burden of electronic documentation can result in more time for patient care. Therefore, nurses should work with informatics workers to implement strategies to reduce the volume of required documentation. Suggestions include:1,11-14


* Simplify data collection requirements as much as possible.


* Implement documentation shortcuts, such as charting by exception, and focused midshift reassessments when appropriate.


* Automate data collection (such as vital signs) via devices that interface with the EHR.


* Avoid adding systems that require dual or extraneous documentation.


* Use the power of automation to make data serve many purposes and avoid redundancy.


* Incorporate specific quality and safety data language into data collection via dropdown boxes and checklists to ensure alignment with best practices and reporting requirements.


* Standardize handoff tools to improve efficiency, safety, and communication during care transitions. Most EHRs incorporate self-populating standard information into the handoff tool. This may include a homepage designed to give an overview of the patient story.


* Incorporate a work list for real-time task recognition and automated reminders into the EHR, especially for unlicensed assistive personnel and patient-care technicians.


* Incorporate existing technology solutions to automate data entry. This could include using handheld devices or interactive whiteboards to automate hourly rounding, which could decrease the incidence of falls and call bell use.




There are usually many reports available from the EHR catalog regarding clinical efficiency and timeliness. Many organizations have additional business intelligence and analytics software that presents performance dashboards and comparative performance reporting.


Nurses should understand the applications of the available reports and nurse managers can learn how to create custom reports to help employees focus on key quality improvement areas. Many organizations have reported that a major benefit of the EHR is the ability to look at patterns in performance data to identify problem areas, facilitating quality improvement initiatives and identifying opportunities for ongoing process redesign.1 Most EHRs allow users to formulate independent queries to explore questions and test hypotheses.1


Stay on top!

Healthcare settings are becoming more complex and technology-driven. As technology challenges increase, there is a coordinated need for nurses to navigate this complex environment. It is critical for nurses to have in-depth knowledge regarding technology and EHR systems to promote optimal nursing workflow and effectively manage technology.




1. Silow-Carroll S, Edwards JN, Rodin D. Using electronic health records to improve quality and efficiency: the experiences of leading hospitals. [Context Link]


2. Ammenwerth E, Mansmann U, Iller C, Eichstadter R. Factors affecting and affected by user acceptance of computer-based nursing documentation: results of a two-year study. J Am Med Inform Assoc. 2003;10(1):69-84. [Context Link]


3. Cornell P, Herrin-Griffith D, Keim C, et al. Transforming nursing workflow, part 1: the chaotic nature of nurse activities. J Nurs Adm. 2010;40(9):366-373. [Context Link]


4. Hendrich A, Chow MP, Skierczynski BA, Lu Z. A 36-hospital time and motion study: how do medical-surgical nurses spend their time. Perm J. 2008;12(3):25-34. [Context Link]


5. Yee T, Needleman J, Pearson M, Parkerton P, Parkerton M, Wolstein J. The influence of integrated electronic medical records and computerized nursing notes on nurses' time spent in documentation. Comput Inform Nurs. 2012;30(6):287-292. [Context Link]


6. Stokowski LA. Electronic nursing documentation: charting new territory. [Context Link]


7. Yeung MS, Lapinsky SE, Granton JT, Doran DM, Cafazzo JA. Examining nursing vital signs documentation workflow: barriers and opportunities in general internal medicine units. J Clin Nurs. 2012;21(7-8):975-982. [Context Link]


8. Wager KA, Schaffner MJ, Foulois B, Swanson Kazley A, Parker C, Walo H. Comparison of the quality and timeliness of vital signs data using three different data-entry devices. Comput Inform Nurs. 2010;28(4):205-212. [Context Link]


9. Collins SA, Cato K, Albers D, et al. Relationship between nursing documentation and patients' mortality. Am J Crit Care. 2013;22(4):306-313. [Context Link]


10. Swartz C. Recognition of clinical deterioration: a clinical leadership opportunity for nurse executive. J Nurs Adm. 2013;43(7-8):377-381. [Context Link]


11. Neville K, Lake K, LeMunyon D, Paul D, Whitmore K. Nurses' perceptions of patient rounding. J Nurs Adm. 2012;42(2):83-88. [Context Link]


12. Ford BM. Hourly rounding: a strategy to improve patient satisfaction scores. Medsurg Nurs. 2010;19(3):188-191.


13. Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds: on patients' call light use, satisfaction, and safety. Am J Nurs. 2006;106(9):58-70.


14. Karriker K. Monitored hourly rounds. [Context Link]