Where did the myth about nurses not welcoming automation to their workflows begin? The benefits of electronic health records (EHR) systems are well known – more efficient documentation of patient care and better treatment outcomes. But a common perception persists that getting nursing professionals to adopt EHRs is like coaxing a child to take a pill: trust me, just swallow it and you’ll feel better.
Concerns about adopting new technology are often valid. Nursing staffs already operate at full steam and may have reservations about the time it takes to learn a new system. Bottom line: Using an EHR as part of the workflow changes established processes, and the nursing staff might not fully understand how it benefits patient care.
Recent studies related to the implementation of EHRs conducted at two large urban hospitals and one rural community hospital provide meaningful insight into the real benefits of moving to automated systems. All three studies examine the impact of automated systems on nurses’ workflows, as well as beneficial outcomes.
While each hospital conducted its own customized study, they all produced similar, positive results. Instead of balking at implementing new systems, the studies found that EHRs enable nurses to:
- Spend more time with patients;
- Improve coordination of care;
- Reduce time spent documenting patient care; and
- Deliver safer care with fewer medication errors.
Study #1 – Nursing Documentation and Barcode Medication Administration; Jefferson Regional Medical Center, Pine Bluff, Ark.
This three-year study uses work-sampling techniques to document the amount of time the nursing staff spent in direct-versus-indirect patient care, with the assumption that more direct care is better because:
- Nurses are the best professionals to know and coordinate patient care. By spending more time with patients, nurses can more actively and intuitively assess patient needs;
- Patient outcomes are better when nurses are able to make sure needs are met; and
- Patient satisfaction with care rises with more direct contact with the nursing staff.
The study is conducted during the same month in each of the three years to normalize study results for patient load, clinical severity and seasonality. The three years of data represent:
- The baseline, during which the EHR was already implemented, along with computer-based provider order entry (CPOE).
- Year 1, with the implementation of the nursing documentation capabilities within the EHR.
- Year 2, with the additional implementation of barcode medication administration integrated with the EHR.
At the end of the three-year study, nurses were observed to spend 1½ hours more time for direct patient care per 12-hour shift, a nearly 30 percent increase (p<.01), see Figure 1. With this boost, direct care – care at the bedside in direct proximity of the patient – is approaching 50 percent of nursing time (p<.001), see Figure 2.
In year 2, the impact of the barcode medication administration is studied. With no change in how medical errors are reported or tracked, Jefferson Regional also tracked a more than 70 percent decrease in medication errors after implementing the Allscripts system.
|Figure 1 – Impact on how much time nurses spent in direct care before and after the implementation of the bedside barcoded medication delivery system. Direct care time rose nearly 50 percent two years after the system was in use.|
|Figure 2 – Direct care nursing time is now approaching nearly 50 percent of every nursing shift, an almost 30 percent increase since year 1 of the study before the barcode system was implemented.|
Study #2 – Staff Perception of Improved Patient Safety using Bedside Barcoding for Medication Delivery; United Regional Health Care System, Wichita Falls, Texas.
Bedside barcoded medication delivery is a known best practice often measured by reductions in delivery errors. Medication errors are typically reported on a voluntary basis and are widely known to be under accounted. United Regional Healthcare System chose an innovative approach by studying the impact on nurses’ perceptions of the implementation of Allscripts. The hospital surmised that when staff is engaged in rolling out a new technology they will use on a regular basis, the associated new processes would be more efficient.
A survey conducted prior to implementation of the new system determined a baseline of staff nurse perceptions of safety, ease of use and documentation when administering medications. A post-survey was conducted after fully implementing bedside barcoding in all inpatient nursing units. More than 400 nurses as participants evaluated the impact of the Knowledge-Based Medication Administration (KBMA) implementation by completing pre- and post-surveys leveraging Likert rating scales from 0-5. The data clearly shows that post implementation, staff perception and rate of medication errors are significantly impacted. In fact, results were overwhelmingly favorable.
|Figure 3 – Composite rankings of questions regarding medication safety, ease of checking the Five Rights of Patient Medication, alerting and reduction/prevention of medication errors (mean=4.15, std. dev.=1.033, n=407).|
The mean composite rating computed across all items evaluating “improved” or “better” was 3.95. Means were significantly higher (p<.0001) for each item for pre-versus-post surveys.
Most significantly, all survey participants answered every medication safety question, producing a very high 4.15 composite rating finding that medication safety improved after the implementation of the EHR, see Figure 3.
Study #3 – Impact of Implementing Automation on Workflow, Staff Satisfaction and Outcomes; Presbyterian Intercommunity Hospital, Whittier, Cal.
Presbyterian Intercommunity was building on a long history of EHR use when administrators decided to add knowledge-based charting. After reviewing survey instruments and methods, the hospital combined both end-user survey and work-sampling studies, along with a data review to answer three compelling questions:
- What did the nursing and ancillary staff think of the move from paper to electronic documentation?
- Would there be a significant change in time spent in nursing activities?
- Could the move from paper documentation to an electronic system be made without adversely affecting outcomes?
Staff is surveyed before implementation of the new system, then again six months and one year post-implementation. A survey with a Likert scale from 1 (absolutely disagree) to 6 (absolutely agree) is used. A neutral choice option is not included. Answers are either favorable or non-favorable.
A pre-implementation survey found the staff already had favorable early expectations of the benefits of the knowledge-based charting. Post-implementation results indicate that, as staff became more familiar with the system over time, the higher their perception of benefits, such as improved coordination of care, safety and outcomes, see Table 1.
Work-study samples were also conducted pre-implementation, then again six months and one year post-implementation on four medical-surgical nursing units over three consecutive days. Every nurse on duty during the study period was observed at a random time within 30-minute intervals.
The largest change occurred in the time nurses spent documenting outside patient rooms one year post-implementation. The data showed a 6 percent decrease, which based on 12-hour shifts equates to a 44-minute decrease in time spent documenting outside patient rooms. Other substantial findings include a 21-minute decrease in overall documentation time.
Nursing time in patient direct care increased 4 percent (p<.001), while indirect patient care also decreased 4 percent (p<.001) for an 8 percent tradeoff (p<.001), see Figure 4.
|Figure 4 – Post-implementation, more time is devoted to direct patient care.|
Analyzing data from the year preceding and following electronic documentation revealed a significant upward trend in the documentation of skin-risk assessments within 24 hours of admission. More importantly, a significant downward trend in the percentage of patients with hospital-acquired pressure ulcers was found. PIH also earned a successful Joint Commission survey eight months following implementation, with the surveyors commenting specifically on the comprehensive care plan evident in the electronic records. Additionally, the hospital saw a significant positive trend in some patient experience scores.
The myth is busted
Studies that have documented nurses’ dissatisfaction with implementing EHRs are likely outdated. As the benefits of electronic documentation and automated systems prove themselves over time, nursing professionals can see the positive outcomes for patients and how they perform their own duties. The three studies outlined above underscore that, no matter how you measure the improvements enabled by EHRs, nurses are better care givers when armed with the right automated systems.
The views expressed herein are the authors’ own and don’t necessarily represent their employers’ position, opinion or strategies.
Denise Authier, RN, BSN, is professional practice coordinator, Presbyterian Intercommunity Hospital, Whittier, Cal.
Pamela Bradshaw, MSN, MBA, is vice president of nursing and clinical services, department of nursing, United Regional Health Care System, Wichita Falls, Texas.
Louise Hickman, RN, BSN, MHA, CLNC, is vice president of patient services/chief nursing officer, Jefferson Regional Medical Center, Pine Bluff, Ark.
Steve Shaha, PhD, DBA, is professor, Center for Policy and Public Administration, University of Utah, and principal outcomes consultant, Allscripts, Chicago, Ill.
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