Healthcare Technology and Coordination of Care


Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings

...the EHR [is] seen by nurses as both a benefit and a source of considerable frustration.


Mary Ann Lavin, ScD, APRN, ANP-BC, FNI, FAAN Ellen Harper, DNP, RN-BC, MBA, FAAN

Nancy Barr, MSN, RN

The electronic health record (EHR) is a documentation tool that yields data useful in enhancing patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs. Although nurses applaud the EHR, they also indicate dissatisfaction with its design and cumbersome electronic processes. This article describes the views of nurses shared by members of the Nursing Practice Committee of the Missouri Nurses Association; it encourages nurses to share their EHR concerns with Information Technology (IT) staff and vendors and to take their place at the table when nursing-related IT decisions are made. In this article, we describe the experiential-reflective reasoning and action model used to understand staff nurses’ perspectives, share committee reflections and recommendations for improving both documentation and documentation technology, and conclude by encouraging nurses to develop their documentation and informatics skills. Nursing issues include medication safety, documentation and standards of practice, and EHR efficiency. IT concerns include interoperability, vendors, innovation, nursing voice, education, and collaboration.

Citation: Lavin, M., Harper, E., Barr, N., (April 14, 2015) "Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings" OJIN: The Online Journal of Issues in Nursing Vol. 20 No. 2.

DOI: 10.3912/OJIN.Vol20No02PPT04

Keywords: Experiential-reflective reasoning, electronic health record, informatics, informaticists, nursing practice, health information technology, standards, documentation, quality, safety, patient responses, patient outcomes

The electronic health record (EHR) is a documentation tool that yields data useful in enhancing patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs (Beck et al., 2013; Harper, 2012a; Towsley, 2013). Although nurses indicate dissatisfaction with the EHR design and cumbersome electronic processes (Sockolow, Liao, Chittams, & Bowles, 2012; Stevenson, Nilsson, Petersson, & Johansson, 2010), they view the EHR and the data generated as an opportunity to improve care, safety, quality, and coordination (Cipriano et al., 2013), as well as a tool to study appropriate nurse staffing and to gauge or predict staffing needs (Beck et al., 2013; Harper, 2012b).

The work of the Nursing Practice Committee (NPC) of the Missouri Nurses Association (MONA) included identifying areas of interest to direct care nurses. One identified interest area was the EHR, which was seen by nurses as both a benefit and a source of considerable frustration. Furthermore, nurses were challenged to articulate their concerns due, in part, to the fact that there was no available taxonomy to describe EHR-related difficulties. This article begins to articulate EHR concerns of Missouri nurses. Realizing that these concerns transcend state boundaries, the MONA NPC decided to share their recommendations with a broader nursing audience with the hope that they would increase participation of all direct care nurses in EHR, vendor, and Health Information Technology (HIT) department decisions and problem solving. In this

...nurses were challenged to articulate their concerns due, in part, to the fact that there was no available taxonomy to describe EHR- related difficulties. The Model

Direct care nurses, at their core, are risk managers. They attach meaning to what is and anticipate ‘what might be.’

HIT and the electronic documentation of nursing care directly influence patient safety.

Committee Reflections and Recommendations for Improving Documentation

The investigation of EHR-associated medication administration

article, we share the reflections and recommendations of MONA nurses with direct care nurses and HIT communities across the nation and around the world.

The goals of this article are to add to the EHR literature by categorizing views of nurses as expressed by members of the MONA NPC and to enhance the computer vocabulary of all nurses, empowering them to voice their EHR concerns to IT staff and vendors and to take their places at the table when health and nursing-related IT decisions are being made. In this article, we will describe the experiential- reflective reasoning and action model used to accomplish these objectives; share committee reflections and recommendations for improving both documentation and documentation technology; and conclude by encouraging nurses to consider how they can develop their documentation and informatics skills.

We used an experiential-reflective reasoning model, one that leads to action, to accomplish our purpose. This model includes consideration of participants’ context, experience, reflection, action and evaluation. This experiential-reflective reasoning model has been incorporated into Jesuit pedagogy for more than 450 years. Within nursing, the Jesuit model has been used as a basis for transformative change (Pennington, Crewell, Snedden, Mulhall, & Ellison, 2013). It is analogous to the learning theory and the change/action research methods identified by Kurt Lewin (Atherton, 2013; Smith, 2001). We used this model to categorize the experiences of the members of the MONA Nursing Practice Committee related to their use of the EHR, to reflect upon these experiences, and to draw up a set of recommended actions.

We reflected and articulated direct care nurses’ concerns regarding the EHR. We involved direct care nurses in this initiative because they plan care used to address the clinical judgments/diagnoses flowing from a nursing assessment and provide care to individuals and/or families. The care itself is designed, through this planning process, to achieve the desired outcomes (American Nurses Association [ANA], 2010; Shake, n.d.).

Direct care nurses are bedside nurses; they include generalists, advanced practice registered nurses, care coordinators, visiting nurses, public health nurses, camp nurses, and school nurses. In brief, they are found in any and every setting where nurses practice. Direct care nurses, at their core, are risk managers. They attach meaning to what is and anticipate ‘what might be’ (Meyer & Lavin, 2005). When they anticipate risk, they conduct surveillance, intervene when necessary, and document not only their risk prevention findings/observations, but their reasoning and clinical judgments, interventions, patient responses and outcomes.

HIT and the electronic documentation of nursing care directly influence patient safety. This is because nursing documentation facilitates real-time communication among all healthcare providers and because electronic documentation allows for its study in proportions never before attempted. If patient safety is to be optimized through EHR use, effective collaboration between nurses and HIT staff is needed, along with greater clarity of the patient safety perspective that direct care nurses offer.

The reflections and recommendations described in this section are not research findings, but rather reports of the experiential/reflective thinking of the committee, categorized under the headings of both medication safety, and direct care nursing documentation and standards of practice. It is from these reflections that recommendations flow.

Medication Safety

NPC members focused primarily on medication safety, with special attention to the prevention of errors and adverse events. They approached the discussion by following the four categories used to organize medication error prevention strategies in the Agency for Healthcare Research and Quality (2012) report. The Nursing Practice Committee felt that the system, as implemented within the EHR, is weighted toward maximizing the safety of the prescribing, transcribing, and

errors is a ripe area for nursing research and/or nurse-led quality improvement studies.

In each of these examples, the data were already contained within the EHR; they simply needed to be connected in a nurse-and-patient- safety-sensitive manner.

dispensing categories (see Table 1). The table indicates that, of the citations retrieved, only 35 were devoted to medication administration. Of these, only two included the word nurse or nursing in the title (Debono et al., 2013; Yuan, Finley, Long, Mills, & Johnson, 2013). There were no nurses as first authors among the 35 citations dealing with medication administration, nor were there any citations from nursing journals. The investigation of EHR-associated medication administration errors is a ripe area for nursing research and/or nurse-led quality improvement studies.

Table 1. Distribution of Citations Retrieved from PubMed Central Database on September 28, 2014

Search string: EHR AND prevention AND

medication error AND…

Number of citations retrieved

More recent and last citation publication


Prescribing 201 2004 - 2014

Transcribing 9 2010 - 2014

Dispensing 69 2005 - 2014

Administering 35 2005 - 2014

Total number of citations and overall range


2005 - 2014

The NPC further recommended that all four categories of prescribing, transcribing, dispensing, and administering (thus including the nursing-sensitive medication administration category) be digitalized and synchronized in the EHR. Such an action would combine bar code medication administration technology at the point of care with real- time medication surveillance of therapeutic goal attainment, enhanced adverse drug-event alerts, and adverse event-surveillance information. In other words, if bar code data could be used to do more than identify the patient and report medication administration doses, the additional synchronization of information would broaden the scope of the medication-administration patient safety zone. This would give nurses more efficient access to information which the nurse actually uses when administering medications. Additional information, triggered by the bar code, might help the nurse to:

Identify and evaluate the appropriateness of the drug dose and route, given the drug’s specific therapeutic goal Respond to an enhanced, real-time medication contraindication/drug interaction check with the EHR, by linking the drug on the same screen with the most recent, clinically relevant laboratory values

For example, if a low serum potassium value were to appear, it would prompt the nurse to request a supplement for the patient receiving a thiazide. It is important to note that the nurse currently takes these steps manually in a time-consuming process, searching for the potassium values while preparing the drug for administration. The electronic process being recommended is both more efficient and safer.

Electronic medication records (eMARs) should also include trending of medications along with clinically relevant laboratory values. Insulin administration in the eMAR should be trended with the most recent plasma glucose and serum potassium levels in a single view, so as to keep busy nurses from having to retrieve the labs from another flow sheet in the EHR.

In each of these examples, the data were already contained within the EHR; they simply needed to be connected in a nurse-and-patient-safety-sensitive manner. Programming of drug administration processes at the point of patient contact, with strategically placed tips and alerts, might lessen medication errors significantly. We authors support informatics research that moves in this direction. We also offer the following additional medication safety recommendations:

Improve user friendliness (screen size, font size, adequate LED lighting for use in darkened rooms) of handheld devices used to bar code scan medications Build in efficient and timely access to laboratory results for all medication providers (physicians, advanced practice registered nurses [APRN], pharmacists, and other direct care nurses).

Use of non- standard materials will cause documentation to appear as if nurses are not meeting patient education/health promotion standards. is imperative that specialty- specific nurses become involved in the selection and updating of computer- generated, patient- education materials to ensure the evidence base and the appropriateness of all materials.

...the electronic health record should allow providers to manually order or sort the problem list.

Finally, we encourage careful consideration of policies governing the use of pharmacy technicians in dispensing medications without direct pharmacist supervision. Boards of Nursing and Pharmacy may want to take up this consideration from a regulatory or statutory viewpoint. EHRs need to reflect the credentials of the person dispensing and administrating the medications to compare medication error rates between and among licensed and unlicensed personnel.

Direct Care Nursing Documentation and Standards of Practice

Appropriate quality care comparisons among and between providers and practices can only be made when standardized processes and products are used. This section will explore three aspects of the patient safety implications of direct care nursing documentation and its unique characteristics from three aspects, including standardization of evidence-based care processes, transparency of the nursing process, and development of an electronic workflow tool to standardize and improve communication.

Standardization of evidence-based care processes. The NPC recommended standardization of evidence-based care processes, including patient educational materials and actions plans, within and eventually across the care setting. Appropriate quality care comparisons can only be made when such standardized processes and products are used. The operational phrase is ‘when standardized processes and products are used.’ If nurses or nurse practitioners use their own materials and do not use, for example, the EHR-generated patient education materials, then they are at a disadvantage when electronic comparisons within and between institutions are made. Use of non-standard materials will cause documentation to appear as if nurses are not meeting patient education/health promotion standards.

Registered nurses, including APRNs, may defend themselves by saying that their own personal materials are the most current and most evidence-based. If this is so, then it is imperative that specialty-specific nurses become involved in the selection and updating of computer-generated, patient-education materials to ensure the evidence base and the appropriateness of all materials. In addition, documents generated by the EHR must be written clearly and simply, in keeping with sound health-literacy and evidence-based patient education strategies and tools Harvard School of Public Health (n.d.). Nurses may also voice concerns about newer electronic documentation methods interrupting workflow, in which case they need to become personally involved in workflow design with vendors or with IT department personnel.

Some may object to the notion of ‘standardized’ care processes, incorrectly thinking it eliminates individualized care. In contrast to this misperception, it is important to recognize that evidence-based practices and standardization of care processes help to assure that the quality of care is optimized for each individual patient. The premises underlying evidence-based practice and standardized care do not negate, but rather heighten, individualization of care, including consideration of personal beliefs, values, and individual preferences. In brief, evidence-based practice and the standardization of care processes enhance the trust patients have in nurses to consistently function on behalf of their best interest.

Prioritization of diagnoses and transparency of the nursing process. The Nursing Practice Committee recommended that nurses make the nursing process more transparent in the EHR for each patient problem requiring nursing care. The Committee also recommended that nurses properly prioritize patient problems in their documentation.

Proper prioritization of diagnoses and a more transparent process are two methods of evaluating nursing documentation. The American Health Information Management Association indicates the electronic health record should allow providers to manually order or sort the problem list (AHIMA Workgroup, 2011). Analogously, nurses need to have the ability to manually order or sort by priority the diagnoses that drive their interventions.

When documentation is poor it is likely that both human and technologic improvements are needed.

Transparency refers to the clarity of the record for its users. Transparency, in more recent times, has come to mean the open sharing of information. For purposes here, we define electronic health record transparency as clear and open sharing of information among providers and with patients. While providers using the EHR have access to information inserted by interdisciplinary team members, access to this information is not always intuitive, nor is its presentation always clear. Systems today do provide patients with electronic access to limited information in their EHRs. However, it is possible that even greater information sharing in the future will further improve the quality of care (Delbanco et al., 2010; Delbanco, et al., 2012).

Development of an electronic workflow to standardize and improve communication. Additionally, the Nursing Practice Committee recommended that the nursing process steps be researched and developed into an abbreviated communication tool, one that would describe and prioritize each individual patient problem for use during handoff at change of shift and also when documenting planning of care during admission, transfers, and discharges. The NPC suggested that nurses apply ANA nursing practice and documentation standards within the EHR using the nursing process model illustrated in the Figure.

Figure. Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation Model

A simple, electronic workflow helps standardize and improve communication of direct care in keeping with the ANA documentation standards (2010), as in the following focused-care example.

Assessment: Data provide information for nurses to arrive at specific clinical judgments (diagnoses/problems). Diagnoses/Problems/Clinical Judgments: Appropriate outcome identification, planning, and implementation of interventions are not random actions, but are actions that are assessment-and-diagnostic-specific. Outcome Identification and Planning: In these two standards, nurses specify the intervention(s) to be used to achieve the desired outcomes, both process outcomes and clinical outcomes. Implementation: Engage the individual/family/community/population in care planning and on the implementation of interventions. Conduct on-going vigilance and act to prevent or to reverse movement toward outcomes that are undesired. Initiate rescue, as needed. Evaluation: Document patient outcomes and make summative statement/analysis, e.g., condition stabilizing/worsening. Continue to modify plan to achieve desired process and clinical outcomes.

The purpose of nursing documentation is to record nursing care provided and patient responses. The old adage, ‘If it wasn’t charted, it wasn’t done,’ still holds today. Because the current standard of care is the nursing process, the steps in the nursing process need to be evident in nursing documentation. If the process is documented, then the practice standard will be judged as ‘met.’ If the process is not documented, then the practice standard will be considered ‘not met.’ This standard holds true for registered nurses at all levels, whether nurses are documenting in EHR or on paper health records.

We authors find human-machine interaction to be interesting. When there is an issue with documentation, those closest to the world of informatics are quick to exculpate the EHR by saying it was never intended to fill a gap in practice. On the other hand, those closest to the clinical world are quick to exculpate themselves by blaming one or more technical features of the EHR. Reality most likely lies somewhere in the middle. When documentation is poor it is likely that both human and technologic improvements are needed.

It may be that standardization of care processes, including clinical decision-support processes, becomes more fully appreciated as the number of Doctor of Nursing Practice (DNP) graduates increase. These graduates are prepared to use new quality improvement technologies; organize and analyze the evidence that flows from their own practice; and compare their practice parameters against those of others. The following paragraph provides an overview of DNP clinical projects designed to improve patient outcomes or reduce patient risk by improving care processes.

Examples of DNP projects that incorporated clinical decision-support processes include: a) establishing criteria for evaluating provider compliance with amiodarone guidelines in primary care (Dixon, Thanavaro, Thais, & Lavin, 2013); b) addressing therapeutic or clinical inertia in the management of patients with diabetes (Apsey et al., 2013; Mackey et al., 2014); and (c) decreasing HbA1C by building confidence in patient ability to select correct portion sizes and complete weekly exercise plans (Beckerle & Lavin, 2013). APRNs, and especially DNP graduates,

Clinical decision support (CDS) information depends on real time data.

Committee Reflections and Recommendations for Improving Documentation Technology

...structured, electronic documentation is more closely associated with quality patient outcomes in primary care than free text or dictated documentation.

know that the ability to take advantage of EHR data to improve patient care first requires the proper entry of process and outcome data in the record.

Appropriate timing of nursing documentation, both real time/synchronous and late charting/asynchronous documentation, requires that nurses have access to and use the EHR at the point of care. Nurses use both synchronous and asynchronous methods to document care . Perhaps when voice activated, natural language processing methods are further developed and better integrated into the EHR, all nursing documentation will be synchronous.

Clinical decision support (CDS) information depends on real time data. Triggering an alert for sepsis is only beneficial if the alert comes as soon as the system inflammatory response system (SIRS) criteria are met. If the vital signs are written on paper and entered later, the alert is delayed and patient safety is impaired.

Continued research is needed in basic nursing care of the ill patient and its documentation (Englebright, Aldrich, & Taylor, 2014; Van Achterberg, 2014). Documentation studies indicate that factors to promote diagnostic reasoning and accuracy have been identified. These factors include use of problem, etiology, and signs/symptoms (PES) structure; computerized aids (e.g. diagnostic specific scales); and standardized care plans (Müller-Staub & Paans, 2011; Paans, Nieweg, van der Schans, & Sermeus, 2011; Paans, Sermeus, Nieweg, Krijnen, & Schans, 2012).

Other methods to improve documentation include nursing documentation audits, use of safety checklists in surgery, and nursing diagnostic-specific checklists (Mykkänen, Saranto, & Miettinen, 2012; Treadwell, Lucas, & Tsou, 2014). Researchers should work closely with EHR vendors and terminology developers to be assured that tools with known validity and reliability are correctly incorporated into the clinical workflow. These scales not only meet nursing and hospital system standards but are increasingly being incorporated into big data and population- health management.

Comparisons of physician documentation suggest that structured, electronic documentation is more closely associated with quality patient outcomes in primary care than free text or dictated documentation (Linder, Schnipper, & Middleton, 2012). On the other hand, unintended consequences may flow from what a clinical ethicist calls EHR quality and documentation pitfalls. Examples include “copying and pasting data from day to day without proper evidence of verification, authorship ambiguities, inadvertent inclusion of un-obtained data in templated notes, ambiguous history and physical examination findings, failure to review prepopulated data, inadequate discharge summaries” (Bernat, 2013, p.1057).

Each of these issues may be prevented or addressed by discussion and exchange of information between the provider, whether physician or nurse, and the vendor and/or IT department. Most vendors provide software with a variety of options for each assessment parameter (e.g., yes, no [not present], no [NA], or deferred). Yet, well- intended but clinically inappropriate IT decisions may be made. For example, in an attempt to save electronic memory/space, a system may be designed to include ‘only’ a single yes/no option for each assessment parameter. In such cases, the EHR nurse/physician on the next shift -- or much later when a case is presented in court -- does not know if a recorded ‘no’ means that the parameter was assessed and found to be negative, or was not assessed because it was not applicable, or was deferred.

When clinicians identify problems, such as ambiguous yes or no options, they are encouraged to correct them by explaining clinical and legal consequences of such decision-making to IT department staff or to healthcare system executives. Other technology issues may also need to be voiced to vendors.

In the paragraphs below, we will first consider efficiency and EHR technology concerns. Then we will offer HIT and nursing practice recommendation.

Efficiency Concerns Related to the Use of EHR Technology

A time and motion study addressing nurses’ work in the acute care setting found that collecting, entering, and accessing data used a large portion of nurses’ time.

...a well- constructed EHR also reflects accurately how nurses think (assess), arrive at clinical judgments (diagnose), identify outcomes, plan, intervene and evaluate care.

Efficiency in the delivery of healthcare is defined as “avoiding waste, including waste of equipment, supplies, and ideas” (Institute of Medicine, 2001, pg 6). Several studies have documented the lack of efficiency in current EHR documentation practice.

A time-and-motion study of resident physicians' note-writing practices using an EHR revealed high fragmentation in clinical work (Mamykina, Vawdrey, Stetson, Zheng, & Hripcsak, 2013). Activities that interrupted documentation included: phone calls, patient requests, and frequent transitions between various types of documentation modalities. Researchers suggested that physicians rely on synthesis rather than composition to write progress notes. Newer technologies that support synthesis are exemplified by highlighting and thus capturing single words or phrases from the chart to construct a new note descriptive of the patient at the current point in time. Another technology would be use of the ‘ready selection of clinically relevant trend lines’ to indicate the patient's current clinical status. Research is needed to compare the quality of such charting and to determine if it is less vulnerable to fragmentation than current charting methods. This research needs to include study of the documentation by both direct care nurses and physicians.

A time and motion study addressing nurses’ work in the acute care setting found that collecting, entering, and accessing data used a large portion of nurses’ time. This resulted in in considerably less nursing time available for patient care (Hendrich, Chow, Skierczynski, & Lu, 2008).

A recent hospital-based study by Englebright et al. (2014) developed a definition of basic nursing care documentation for the adult patient and integrated it into an EHR. The researchers concluded that this newer method minimized or eliminated documentation that did not directly support patient care. These investigators recommended use of alternative options for recording non-patient-care-related information and use of EHR technology to help nurses document and communicate basic care elements.

The Nursing Practice Committee of the Missouri Nurses Association is committed to efficiency in the provision of care. These nurses recognize that efficiency, including efficient capture of meaningful data, helps to translate information and to communicate nursing-based knowledge to other members of the healthcare team, thus improving patient safety and care quality. The MONA Nursing Practice Committee has recommended:

Ease of access and availability to computer devices in patient rooms. Emphasis should be on positioning of the computer to augment the engagement of the nurse and the patient as partners in care. Because no single device will work in all care areas, nurses should consider multiple types of computer device options. The number of devices available should be contingent upon the number needed to cover high volume times of day. High reliability/consistency when accessing/using computers on wheels. Variables to consider include quality of the wireless connection, battery life limitations, and available bedside space. Improvements in the ‘time-to’ issue. Examples include time-to-sign into the record, time-to-save nursing documentation, and time-to-switch between screens to review all aspects of the patient’s chart.

Efficiency-related issues, if unaddressed, minimize electronic documentation. Given a choice between providing high quality care and quality documentation within an inefficient EHR system, it is safer to provide the care required and minimize documentation time than to compromise on care to be sure that documentation is complete. Understanding and correcting the etiology of such documentation work-arounds, and all other work- arounds, is essential to improving the healthcare system (Debono et al., 2013). Members of the Nursing Practice Committee have recommended that, if current systems are inefficient or suboptimal, the goal for nurses, IT staff, and institutional administrators should be to improve the system not work around it.

Direct care nurses report that EHR issues also affect the quality of their charting. These include, when using some products, rigidity in the number of available options for entering nursing data; a lack of pertinent patient information presented in a readily accessible and comprehensible manner to support critical decision making; drawbacks associated with over-dependence on the checklist quality of nursing documentation; and the relatively little attention given to diagnostic-specific interventions and their evaluation. Such issues lead to poor visibility, presentation, and possible incorrect use of clinical information that may compromise patient outcomes.

Issues related to electronic charting, however, may not always be the fault of the EHR. Documentation, electronic or otherwise, reflects the critical thinking of the nurse and the quality of the nursing care itself. In other words, correct or solid human reasoning is needed to interpret data collected correctly, make appropriate clinical judgements, act upon them competently, and document clearly. When such is lacking, the lack is evident in the documentation. In addition to it being a vehicle that facilitates big data research, the EHR may be used to facilitate the regular review of randomly selected records for documentation case reviews and quality improvement purposes. For example, a random review may reveal findings like those indicated in Table 2, which illustrate that the EHR is not a substitute for incorrect thinking. In fact a well-constructed EHR reflects, as Table 2 shows, lapses in adhering to nursing standards. Conversely, a well-constructed EHR also reflects accurately how nurses think (assess), arrive at clinical judgments (diagnose), identify outcomes, plan, intervene and evaluate care (Lang, 2008).

Table 2. Case Scenario

An EHR documents practice and reflects the quality of underlying direct care nurse thinking; it does not replace thinking or serve as its substitute but reflects adherence to or lapses in adherence to nursing standards.

User case scenario: 68 year old female admitted to nursing unit with diagnosis of pneumonia and history of heart disease. Temperature at 101° F; blood pressure 148/92; heart rate 96/min (regular rate and rhythm); respiratory rate 28/min; and pulse oximetry 93%. Patient denies pain but complains of increasing fatigue, cough and shortness of breath. The admitting RN documents the initiation of intake and output; daily weights; and vital signs; including pulse oximetry, four times daily.

Standard 1. Assessment Documentation

RN collects comprehensive data pertinent to the healthcare consumer’s health or the situation.

Over the course of the next few days, the RN staff collects pertinent data. Intake and output records reveal an alarming fluid volume overload. Vital signs reveal a decrease in fever but a steady increase in systolic and diastolic pressures, increasing heart rate, and slowly declining oxygen saturation.

Standard 2. Diagnosis Documentation

RN analyzes the assessment data to determine the diagnoses or issues.

There is apparently no attempt to analyze the data or report it to the attending physician. Fluid volume overload is not mentioned in the patient record, although the patient’s fall risk and skin integrity are noted.

Standard 3. Outcome Identification


RN identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.

No expected outcomes are identified. There is also no mention of the increasing risk of pulmonary edema/congestive heart failure due to increasing fluid volume overload. On the fourth day, the patient develops acute pulmonary edema and is transferred to Intensive Care Unit (ICU).

Standard 4. Planning Documentation

RN develops a plan of care that prescribes strategies and interventions to attain expected outcomes.

While the prior plan of care included appropriate surveillance activities (e.g. intake and output, daily weights, pulse oximetry and appropriate vital sign monitoring), nothing was done to conduct surveillance at regular intervals or to adapt the plan of care appropriately – i.e., report and control fluid volume overload and report signs of impending heart failure to the physician. In other words, electronic nursing documentation of surveillance activity was haphazard and findings did not lead to appropriate implementation.

Standard 5. Implementation Documentation

RN implements interventions identified in plan.

This case scenario begins and ends with the collection of data. There was no documented professional analysis of the data or diagnosis, nor was a plan of care appropriate to the patient’s needs documented.

Standard 5A. Coordination of Care

There was no documented coordination of patient care.

Standard 5B. Health Teaching and Health Promotion

There was no documented health teaching or health promotion.

Standard 5C. Consultation (Graduate Prepared Specialty or APRN)

Not applicable

Standard 5D. Prescriptive Authority and Treatment (APRN)

Not applicable

Standard 6. Evaluation.

RN evaluates progress toward attainment of outcomes.

Patient outcomes (pulmonary edema) could have been prevented had assessment data been correctly analyzed and the diagnosis of fluid volume overload recognized. As it was, the patient was admitted to ICU, appropriate treatment was initiated, and patient was discharged home, but length of hospital stay had been extended and the patient now has a history of congestive heart failure, recent onset.

Lapses in reasoning, documentation, and actions were also present during the paper-chart era. The difference is that the extent of these lapses could not be readily evaluated with paper charts. On the other hand, the use of the EHR enhances the ability to conduct retrospective reviews of databases and identify the extent of lapses in professional documentation/care. Consequently, electronic audit technology creates opportunity to systematically improve, on a large scale, care quality and/or its documentation (Baus, Hendryx, & Pollard, 2012; Golberg, Mick, Kuzel, Feng & Love., 2013).

HIT and Nursing Practice Recommendations

A foundational aspect of interoperability is the use of a core set of taxonomies to communicate between all disciplines interacting with the patient.

Nurses need to be at the table when vendor-selection decisions are made.

The reasoning model we used also facilitated the expansion of our thinking and enabled us to arrive at a number of broad recommendations. In the following paragraphs, we discuss HIT practice recommendations, Health IT department concerns, and nursing practice recommendations.

HIT practice recommendations. This section presents HIT issues raised by participants. We offer recommendations to address interoperability, vendor concerns, IT department concerns and the need to innovate.

EHR interoperability concerns raised by participants included the lack of interoperability of computer systems between provider offices, hospitals, extended care facilities, home health agencies, community health centers, and schools (McMurray et al., 2013). Lack of interoperability leads to poor coordination of care and less than efficient care transitions between and among agencies, thus increasing the potential for error. A foundational aspect of interoperability is the use of a core set of taxonomies to communicate between all disciplines interacting with the patient. The ANA (2006) currently recognizes 13 taxonomies. Of these taxonomies, only the Standardized Nomenclature of Medicine – Clinical Terms (SNOMED-CT) represents a standardized terminology that supports nursing practice as well as the practice of other health disciplines. Nurse informaticists provide leadership in the development and application of these terminologies. Also needed is continued and even more input into the architecture of clinical patient care within HL7, the organization that addresses the standards for interoperability

of health information globally (Health Level Seven® International, 2014).

The Nursing Practice Committee recommends that more Missouri nurses become both certified in informatics and members of informatics/health information technology organizations. They will then be positioned to advocate for the adherence to both HIT and to nursing standards within the EHR. They will be the experts who know that nurses are expected to document in accord with ANA nursing standards. They will have the background to contribute directly to the EHR display so that it represents practice in accord with ANA nursing standards as well as the HIT standards.

The Nursing Practice Committee also addressed vendor concerns. The Committee noted that when practice concerns were voiced to informaticists, a frequent response was: “Have you expressed these concerns to the EHR vendors?” The general consensus was that there are both non-responsive and responsive vendors. Non-responsive vendors pay little heed to clinical nurses other than to ‘teach’ them how to use the system. These vendors spend minimal time listening to the needs of clinicians not employed by the vendor’s company. On the other hand, responsive vendors employ nurses who are both experienced in the clinical workflows and possess advanced education in the sciences of nursing, informatics, and computers. They work with clinicians with the end result being significant

improvements in workflow and user (nurse) friendliness of the system. Nurses need to be at the table when vendor-selection decisions are made.

Health IT department concerns. Sometimes vendors may be blamed for non-responsiveness when IT department personnel do not communicate nurse concerns to vendors. Nurses identified such communication issues within two large and separate Missouri healthcare systems. IT departments blocked the flow of information from nurses to vendors. Instead of transmitting concerns, IT staff proffered such reasons as: the software did not allow such a change, the system was not designed to function in that way, and software updates permitting access to newer versions were not possible at this time. This may be reflective of the IT department’s limited time and resources due to competing IT projects, or the lack of nurses at the table when IT project priorities are set. It is essential for clinicians to be engaged in all clinical IT projects.

In terms of needed innovation, the Nursing Practice Committee believes there are multiple opportunities to improve clinical practice and, equally important, to embrace evidence-based practice through innovative HIT initiatives. Suggested initiatives include:

Use clinical decision support technology to create nursing care alerts, not unlike medical, laboratory and medication risk alerts (Sidebottom, Collins, Winden, Knutson, & Britt, 2012). Build into the EHR patient-centric, real-time quality and operational dashboards, audits, and comprehensive retrospective reviews of the quality of nursing documentation (Patterson et al., 2013; Tan, Hii, Chan, Sardual, & Mah, 2013). This helps assure the inclusion of nursing data in big data warehouses. This facilitates the study of large datasets to generate new knowledge to find, for example an optimal balance between patient outcomes and staffing ratios and optimal patient levels of care or patient throughput (Checkley et al., 2014; Harper, 2012b). Continue to develop standardized, nursing sensitive eMeasures, facilitating automatic summaries and comparisons within and between nursing units and healthcare systems. The use of these measures provides the basis for the development of quality improvement programs and new research initiatives.

Just as the Nursing Practice Committee recommended general health information technology recommendations, they also recommended actions to strengthen nursing’s informatics knowledge base and to remind nurses that nursing knowledge is power.

...the nursing profession cannot wait for attention until more power is granted to nurses within an institution nor until cost- benefit analyses justify their value to the institution.

... all nurses from all backgrounds have a vested interest in increasing the visibility of nursing practice through use of the electronic health record.

Nursing practice recommendations. Each of the following directives enhances the power base of nurses within the field of informatics. Areas discussed include voicing nursing’s concerns; improving basic informatics education; reviewing and advancing nursing sensitive EHR technology; increasing collaboration between health IT and nursing standards; and making nursing practice visible.

A nursing voice may be lacking because nurses are not perceived as healthcare system decision makers or revenue generators. Hence, their input may be dismissed without due consideration. This major concern needs to be addressed in nursing. Physicians are vocal and evoke attention that motivates vendors to listen. However, the nursing profession cannot wait for attention until more power is granted to nurses within an institution nor until cost-benefit analyses justify their value to the institution. Rather, resolution lies in nurses simply assuming that they have the power to articulate their value and to expect solutions that measurably improve electronic documentation and communication, patient safety and quality care. We need to share stories about the Missouri nurses, and all nurses, who have exercised health IT power in meaningful ways and who have been responsible for improvements in practice.

Although the American Association of Colleges of Nursing considers informatics essential nursing knowledge within baccalaureate, masters, and doctoral degree programs, the current lack of basic informatics education within nursing programs, coupled with the failure to expect graduates to exhibit informatics competencies, remains an issue. This deficit extends beyond learning how to document and communicate within an EHR, and leads to a reciprocal problem: lack of capacity to prepare clinical nurse informaticists in sufficient numbers to process needed requests in a scientifically sound and evidence-based manner. This article is, therefore, a call to all nurses to become informed regarding nursing informatics and pursue additional informatics educational opportunities. The Nursing Practice Committee has recommended that the number of Missouri nurse informaticists be tracked and that methods of incentivizing nurses to become informaticists be considered. This is important for all states within the United States and for nurses around the world.

It is also important for nurses to review, study, and advance nursing sensitive EHR technology. Nurses need to join informatics or informatics-related organizations (e.g., Healthcare Information and Management Systems Society, American Nursing Informatics Association, American Medicine Informatics Association as well as patient safety organizations. Advanced practice nurses are encouraged to join standards-setting organizations (e.g., Health Level

Seven® (HL7) or the Healthcare Informatics Technical Committee of the International Standards Organization [ISO]).

Deepening collaboration between health IT standards technology and nursing standards practice at point-of-care is also important. Standards-based health IT has been shown to facilitate communication and information flow among interprofessional team members caring for children receiving palliative care (Madhavan et al., 2011). Standards-based nursing practice is the norm and is written into each State Nurse Practice Act. Increased collaboration and closer coordination between HIT standards-based technology and standards-based nursing practice is indicated. Join your agency/institution IT committee!

Finally, we must make nursing practice more visible by closing the gap between nursing practice standards and EHR documentation of care. As authors, we realize that there is a direct patient care and physiological outcomes bias in this article. It reflects the nursing background of the authors and Maslow's priorities, as well as Florence Nightingale's interests in the Crimean War (e.g., decreasing infection rates and mortality rates). However, the principles discussed to make nursing practice more visible are applicable to all aspects of care.

Our main point is that all nurses from all backgrounds have a vested interest in increasing the visibility of nursing practice through use of the electronic health record. Communicating effectively with informaticists and helping them develop documentation measures that reflect the full spectrum of evidenced-based and standards-based nursing practice advances this objective. Simultaneously, we need to position nurses to exert greater influence in the transformation of healthcare for the benefit of all. Nurses are good strategists, problem solvers and decision-makers; they are committed to the National Quality Strategy having the ‘triple aim’ of improving care, improving health and lowering costs (Agency for Healthcare Research and Quality, 2014).

Summary and Conclusion

This article categorized the concerns of nurses expressed to or by the members of the Missouri Nurses Association Nursing Practice Committee on the subject of electronic health record documentation. It is hoped that this


information will enhance the informatics vocabulary of direct care nurses and build confidence in their ability to sit at the HIT table to address issues that directly affect patient safety, care quality and the documentation of care. Broader informatics concerns were addressed as well, both from an HIT and a nursing perspective. From an HIT perspective, interoperability remains a significant HIT concern. Vendors and IT departments need to be rewarded for their responsiveness to this nursing concern. Conversely, those who remain unresponsive need to be held accountable.

Innovation, including increasing use of big data and eMeasures, will continue to improve patient safety and care quality. From a nursing perspective, we hope this article will help empower direct care nurses and the nursing profession to better articulate nursing informatics concerns and also to value and improve the role the EHR plays in making visible the practice of nursing.

The Nursing Practice Committee recognizes that the EHR cannot address documentation deficiencies. Therefore, we encourage you as a direct care nurse to identify where you are in this process. Plan how you want to best develop your own documentation and informatics skills. We conclude with three possible development scenarios. If you know how to document the nursing process appropriately, work with vendors and IT staff to communicate your knowledge, observations and suggestions to them. If you know how to document the nursing process appropriately, but do not do so regularly, reflect on why and develop a plan to correct your own inaction or to identify and correct barriers within the system that hinder appropriate documentation. If you lack the ability to document the nursing process in the care you provide, develop a continuing education plan that helps you build this skill. Regardless of the scenario in which you best fit, act smartly upon your reflections, with the objective of improving practice and education institutionally, locally, nationally, and globally.


Mary Ann Lavin, Ellen Harper, and Nancy Barr are members of the Missouri Nurses Association (MONA) Nursing Practice Committee. Their health information technology recommendations in this article are an outgrowth of the issues and problems that they have heard members express. They are grateful to the Nursing Practice Committee for the wealth of information presented, as this has allowed for the categorization of the data. It is their hope that such a categorization will help nurses name and communicate their concerns more clearly, and contribute directly to the design decisions made.

Mary Ann Lavin, ScD, APRN, ANP-BC, FNI, FAAN Email: [email protected]

Dr. Lavin is a graduate of St. John’s Hospital School of Nursing in St. Louis, MO; Saint Louis University (BSN, MSN); and Harvard School of Public Health (MS, DSc), Boston, MA. She is an advanced practice nurse, board certified as an adult nurse practitioner, and a charter fellow in both NANDA International and the American Academy of Nursing. Dr. Lavin was an early leader in nursing diagnosis classification, co-coordinating the First National Conference on the Classification of Nursing Diagnosis in St. Louis, Missouri in 1973. She is a member of NANDA-International, serving on the Board and later as President. In 2011, she was inducted into the Missouri Nurses Hall of Fame. Dr. Lavin is a member of the American Nurses Association (ANA) Working Group on the Scope and Standards of Practice, a member of Missouri Nurses Association Nursing Practice Committee, founder of the Network for Language in Nursing Knowledge Systems (, and an independent nursing and healthcare consultant. Until her retirement from Saint Louis University in June 2014, she chaired Doctor of Nursing Practice capstone projects, taught advanced pharmacology and interprofessional patient risk reduction collaboration methods, and served as the nurse lead in the Southern Illinois University Edwardsville-Saint Louis University Center of Excellence in Pain Education.

Ellen Harper, DNP, RN-BC, MBA, FAAN Email: [email protected]

Dr. Harper received an associate degree from Iowa Central Community College in Fort Dodge, Iowa, a bachelor’s degree in healthcare management from Ottawa University in Kansas City, MO, a master’s degree in business from the University of Phoenix, Kansas City, MO, and a Doctor of Nursing Practice degree from American Sentinel University in Denver, Colorado. Dr. Harper, a board certified nurse informaticist, is Vice President and Chief Nursing Officer at Cerner Corporation in Kansas City, MO. She has more than 30 years of experience in healthcare, of which more than 20 years have been focused on using technology and informatics to automate evidence based, interdisciplinary, patient-centered workflows. She is a fellow of the American Academy of Nursing. Her research interests include: the development and testing of eMeasures to advance the science of nursing practice; evidence- based staffing; big data and the economic value of healthcare data and its implications for practice and research; and the evolution and growth of evidence-based science; and demonstration of the value of interprofessional inclusivity in maximizing patient-centric care.

Nancy Barr, MSN, RN Email: [email protected]


Ms. Barr is a graduate of St. Mary’s Hospital School of Nursing, Kansas City, MO, Avila University (BSN) in South Kansas City, MO, and the University of Kansas School of Nursing, Kansas City, KS. She is a clinical assistant professor at the University of Kansas School of Nursing, Her clinical involvement with the University of Kansas undergraduate nursing students requires a working relationship with several vendors of acute care electronic health records (EHRs). Additionally, she uses an office-based EHR, which requires meaningful use as it was implemented via the federal guidelines for primary care providers in an office setting, one of the largest privately owned medical groups in the Midwest. Barr is active as the Chairperson of the Missouri Nurses Association Committee on Nursing Practice and co-chair of the Missouri Emergency Nurses Association Nursing Practice Committee. She is also active with the Missouri Action Coalition, and is responsible for some aspects of the implementation of the Affordable Care Act (computer-driven enrollment).

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