ELECTRONIC HEALTH records (EHRs) are consistently used by external organizations to track the quality of care provided based on the information documented in the medical record, which affects hospital accreditation and reimbursement.1 However, some are concerned that technology may cause some patients to feel as if nurses and other practitioners are documenting for the institution instead of caring for patients and their specific needs.1 Therefore, with the integration of bedside nursing and EHRs, nurses must understand the impact of technology on patient-centered care to safeguard the dynamic relationship between the patient and nurse.
The National Academy of Medicine (formerly the Institute of Medicine) defines patient- and family-centered care-also called person-centered care-as care that is planned, delivered, managed, and continuously improved in active partnership with patients and their family to ensure integration of their health and healthcare goals, preferences, and values.2 For patient-centered care to be effective, nurses must utilize technology effectively. This article examines patient and practitioner concerns surrounding EHR usage and proposes recommendations for improvement.
Literature review
This author conducted a literature review using the PubMed database with the following search terms: patient-centered care, nursing, technology, electronic health record, and impact. The review revealed a mostly negative connotation associated with the use of EHRs in healthcare. According to Hunt and colleagues, many practitioners do not believe that EHRs capture the full extent of the patient's healthcare needs.1 Instead, they require practitioners to fit the patients' signs and symptoms into premade boxes that may not accurately represent the complexity of the patient's clinical status. An article by Dillard-Wright suggested that the creation of EHRs shifted nursing priorities from patient-oriented to task-oriented and inadvertently decreased nurses' ability to think critically because EHRs began to dictate the nurse's actions.3 Additionally, a nursing survey found that most nurses were unhappy with EHRs and do not believe that an information technology department is able to develop an adequate and beneficial documentation system focused on patient care.4 According to Hoover, nurses feel EHRs are time-consuming and decrease time at the bedside.4
Moreover, as EHRs relate to data collection, they have shifted the focus from the patient to institutional and organizational priories.5 For example, a review by de Ruiter and colleagues mentioned the development of the Braden Scale and the requirement to document patient repositioning every 2 hours to prevent pressure injuries as institutional priorities rather than patient-centered ones.5 The Centers for Medicare and Medicaid Services will not reimburse institutions for expenses related to certain preventable adverse events such as hospital-acquired pressure injuries. Consequently, nursing care and documentation are often dictated by the institution's financial interests and not necessarily by patient-centered care.
A study by Asan and colleagues found that patients had an unfavorable view of EHRs as well, perceiving that the practitioner focused more on the screen than the patient.6 Hunt and colleagues suggest that the negative view of EHRs is further accentuated by practitioners asking repetitive questions and questions not pertaining to the patient due to the requirement to check off boxes.1
In addition, Asan and colleagues found that patients were not in support of providers utilizing the EHR if they felt that the practitioner was focusing too much on the computer, did not make eye contact, did not listen, or typed excessively.6 Conversely, patients were comfortable with the practitioner using EHRs if he or she made good eye contact, focused on the patient, and listened.6
As suggested by Zhang and colleagues, patient-centered care is achieved in part by communicating effectively, engaging the patient, and providing adequate eye contact to help build rapport and trust. By incorporating those actions, nurses are better able to partner with patients, respect their preferences, and support them through medical decisions.
For practitioners, the use of technology allows them to monitor patients remotely and offers built-in safeguards to alert them to critical results and evidence-based practice recommendations. At its best, technology can help to decrease errors, permit patients and clinicians to communicate, and give patients access to their test results at home.7 A study by Hessels and colleagues found that the use of EHRs also helped to decrease readmissions and reduce lengths of stay.8
However, the literature reveals that technology alone was not enough to increase patient satisfaction. In fact, nursing support, adequate staffing, resources, and technology all need to work together to provide quality patient-centered care at the bedside.8 Overall, a disconnect between technology and patient-centered care as it relates to healthcare was apparent.
Because most of the literature discusses the relationship between physicians and patients, there is also a gap in the literature on this topic as it relates to nursing. Furthermore, few studies discuss how nurses can become engaged in contributing to changes with EHRs to improve overall nurse and patient satisfaction. Research on patients' perceptions of patient-centered care in a way that could be objectively measured was also limited. Most important, a literature gap was found relating to how nursing may facilitate patient-centered care in association with technology to improve patient satisfaction, patient outcomes, and healthcare in general.
Integrating technology and patient care
These findings have important implications for nursing education as well as clinical nursing. For example, nursing instructors need to educate their students on the impact of technology on bedside nursing. Instructors must incorporate solutions for integrating technology and nursing care during their lectures and clinical rotations. Moreover, students must understand how EHRs contribute to healthcare reimbursement and how technology may be used to involve patients and encourage them to take control of their own healthcare.
For clinical nurses, EHRs have been associated with a shift from providing patient care to ensuring that all documentation is correct and completed. Most documentation requirements have been created for the purpose of meeting the institution's priorities, such as reimbursement, billing, quality, safety, and accreditation standards. Because nurses are the primary providers in bedside care, it is imperative that they understand how valuable their input is with regards to electronic documentation. Nurses must encourage their organization to engage them in EHR formatting so that EHRs accurately reflect nursing care and facilitate flow and ease of use.4
According to Frampton and colleagues, the focus on the patient and family creates a general atmosphere of improved care and increases patient satisfaction.2 Educating patients at their literacy level, providing empathy and compassion, and involving the patient in all decisions has also been proven to positively effect healthcare outcomes. Because nurses interact with patients the most, nurses who understand the effect technology has on the care being provided are in an advantageous position to ensure it is being developed and used in ways that support and encourage patient-centered care.
Recommendations
Based on the literature, nurses can use multiple techniques to integrate patient-centered care with technology. For example, Asan and colleagues suggest that clinicians share the computer screen with patients.6 Allowing patients to see their EHR would improve patient involvement and foster education. In addition, it allows for a sense of collaboration with the healthcare team and inspires trust and confidence in the care provided.
Another suggestion is to improve the layout of the treatment rooms. The study by Asan and colleagues suggested that patients and practitioners felt the typical layout of treatment rooms is inefficient for documentation and patient care. By reorganizing the room, a computer could be positioned so that the nurse can see the screen while also maintaining eye contact with the patient. In addition, placing a stool in the room would allow the nurse to sit and talk with the patient while utilizing appropriate nonverbal communication, such as touch. In nursing, the act of sitting while talking to patients encourages patients to share information and engage in their healthcare. It also shows patients that the nurse wants to take the time to talk with them and provide holistic nursing care.
Healthcare professionals could also stop typing while talking to the patient. One study found that making eye contact with the patient before and after typing improved patient satisfaction.7 Also, simply explaining to the patient beforehand that you will be using a computer helps them to know what to expect.
Multitasking while talking to patients may cause them to feel as though they are unimportant or that the nurse is not listening to them and their concerns.7 By learning to actively listen to patients, nurses can convey empathy, compassion, caring, and strong verbal and nonverbal communication. It also promotes respect and support for patients and their healthcare.
These recommendations may be used in nursing education for both students and staff development. With the advancement of technology and the focus on patient-centered care, instructors can educate their students on therapeutic communication and interacting with the patient despite the demands of technology. Instructors can provide their students with the skills to incorporate technology into their patient care in a way that benefits the patient. If students can learn these skills while they are in school, they can transition them to the bedside and help educate experienced nurses about effective techniques.
For staff development, organizations should encourage their nurses to participate in meetings about EHR technology and emailing suggestions for improvement. In addition, administration should be sure to include clinical and nonclinical nurses in the design of new electronic documentation as well as any updates and necessary training.4 By actively involving nurses in technologic updates, organizations can improve nursing satisfaction, patient care, documentation, and healthcare in general. Involving nurses also empowers them to contribute to their profession in a way that positively impacts nurses and other clinical staff, the organization, healthcare, and ultimately the patient.
Final thoughts
Despite its drawbacks, technology has the capability to be a wonderful tool to help nurses work with their patients, engage them in their healthcare, and educate them to make informed healthcare decisions (see How technology can benefit patients). Technology does not have to hinder the nurse-patient relationship. Nurses have the unique ability to improve patient care by getting involved and helping to develop electronic documentation systems that enhance patient-centered care.
How technology can benefit patients
Technology can help patients get involved in their healthcare. For example, nurses can share quality websites with patients and encourage them to research their disease processes. In addition, nurses can educate patients on obtaining their medical records online and communicating with their healthcare team electronically. Applications can be downloaded on cellphones to help empower patients to make healthy choices regarding their health and wellbeing. As nurses, we need to find ways to balance institutional documentation requirements with patient care and education.
REFERENCES