1. Stein, Dylan MSN, RN, CPNP-PC
  2. Travers, Jasmine PhD, RN
  3. Merrill, Jacqueline A. PhD, MPH, RN, FAAN, FACMI


Nurses can influence choices about EHR systems and their design.


Article Content

Federal laws enacted over the past decade, including the Affordable Care Act, promoted health information technology (HIT) as a remedy to a crisis in health care costs and quality. We are now moving toward a value-based model that pays for results over billable services and uses HIT as its backbone. The data gathered through HIT, specifically in electronic health records (EHRs), have begun to clarify the relationship between interventions and outcomes. But are EHRs capturing nursing's role in creating those positive outcomes?


EHR data that link interventions with patient outcomes in a constantly "learning" health care system allow for dynamic improvement in patient care. As defined by the Institute for Healthcare Improvement, this approach has a "Triple Aim": to achieve the best experience of care at the lowest cost, and ultimately, better health for the nation overall.


When EHRs reflect the work nurses actually do, we are equipped with data to evaluate our profession's substantial contributions to those aims. However, because EHRs are the product of an era favoring volume of billable services, nurses often experience them as frustrating and inconsistent drains on precious time. The nuances of our care get lost in task-oriented, quantitative drop-down menus and checkboxes, while the qualitative value of our interventions and impressions are not encoded in a useful way. As the providers who spend the most time with patients, it is critical that the full scope of our work be accurately accounted for when interpreting outcomes.


EHRs that log nursing activities-from observation of subtle signs of deterioration to patient education to interpersonal connection and conversation-are essential to capturing evidence of the importance of nursing within the value-based system. Every health care institution with an EHR should have a nursing informatics committee (NIC) that meets regularly to evaluate if its EHR is meeting this goal.


There are three priority areas for staff nurse involvement. The first is to participate in making sure EHRs are optimized to streamline workflows, prioritize care over charting, and support, not detract from, patient interaction. For example, at our institution, nurses and nursing attendants had different EHR workflows for entering patient outputs. Attendants' entries were not correctly reflected in daily totals, prompting nurses to re-input data. At a neighboring institution, an integrated messaging system for nurses to contact pharmacists poorly displayed alerts; messages were missed, leading to time spent calling the pharmacy to follow up. These issues had easy solutions but required nurses who used the system to speak up. Staff nurses with EHR documentation experience that allows them to distinguish between helpful changes and hindrances are best suited to do so.


A second priority is to assist with implementing standardized data entry and nursing languages (for example, the Omaha System). Standardization supports outcomes evaluation and demonstration of nursing's role in those outcomes. It also saves time by taking the guesswork out of data entry and can overcome limitations in generic EHRs until a NIC can request EHR customization.


Finally, it is a priority for nurses to participate in NICs as subject matter experts for general and specialty nursing content. Rewards for participation should be determined in advance. Research shows that public recognition and paid time off can be more effective than monetary incentives. Nurse managers should identify informal leaders on their units and engage them through recognition of their contribution.


When HIT systems are designed to capture standardized records of nursing actions, an outcomes-oriented, learning health care system will be possible. Accurate recording of nursing actions will demonstrate value in today's shifting health care landscape, which in turn will support our work, advance our profession, and support our advocacy for better care for patients. First, we have to let administrators know how EHRs are failing us, and then direct the improvement process toward our goals.


So, serve as a subject matter expert on your NIC, help create a reference model for capturing data in your area of expertise, and advocate for incentives for staff nurses to participate.