updated- Understanding Design Flow

INSTRUCTOR’S RESPONSE BELOW.

I really enjoyed your discussion of benchmarking, flowcharts, and usability evaluations. The Meaningful Use initiative has escalated the adoption of Health IT systems in the last few years. It concerns me that there is little research on the usability of these systems and impact of these systems on workflow. I read an alarming poll recently that I thought you may be interested in. 

"Black Book polled nearly 14,000 licensed registered nurses from forty states, all utilizing implemented hospital EHRsover the last six months. Survey respondents also ranked the vendor performance of nineteen inpatient EHR systems from a nursing satisfaction perspective. Although the inpatient EHR replacement frenzy has calmed temporarily, the frustration from nursing EHR users has increased exponentially,” said Doug Brown, Managing Partner of the survey firm Black Book Market Research. “The meaningful use financial incentives for hospitals have many IT departments scurrying to implement these EHR’s without consulting direct care nurses, according to the majority of those polled by Black Book.”

· 90% of EHR nursing users attested that the use of the current EHR system in their facility has negatively impacted communications between nurses and their patients.

· 94% of nurses do not believe that the use of their current EHR has improved the communication between the nurse and the care team (physicians, respiratory therapists, physical therapists, occupational therapists, pharmacists, etc.).

· Only 26% agree with the statement, “As a nurse, I believe the current EHR at my organization improves the quality of patient information.”

· 51% of nurses working in hospitals with greater than 100 beds report that all care team members at their organization access and document on the same EHR screens.

“Technology can help nurses do their jobs more effectively or it can be a highly intrusive burden on the hospital nurse delivering patient care,” said Brown. “Many compounding nurse productivity problems of can be sourced to the failure of those selecting and implementing an EHR to involve direct care nurses in the process.”

· 30% of nurses believe their hospitals’ IT departments and administrations respond quickly to making changes in the EHR that the nurses recognize as vulnerabilities in documentation. Alarmingly, 69% of nurses in for-profit inpatient settings report their IT department as “incompetent” when describing the level of expertise their organization’s in-house staff has working with the selected EHR software.

· Nurses working in for-profit, chain facilities are the most exasperated. 98% are dissatisfied with the time allowed to be spent with patients versus the time allowed to document on the myriad of electronic medical record and departmental programs with no connectivity that their hospitals have accumulated.

“Add to that the unique software interfaces from medical equipment and the multiple EMRs each individual physician’s office, it’s no surprise that hospital nurses are getting discouraged and seeking employment in less complex organizations,” said Brown. “EHRs have become an advantage for some hospitals in attracting top nursing talent, but in many cases a poorly implemented EHR with chaotic processes and bungling IT support is becoming a detriment to hospital nurse retention and recruitment. 

· 79% of job seeking registered nurses reported that the reputation of the hospital’s EHR system is a top three consideration in their choice of where they will work.

· Nurses in the 22 largest metropolitan statistical areas are most satisfied with the usability of Cerner, McKesson,NextGen and Epic Systems. Those EHRs receiving the lowest satisfaction scores by nurses include Meditech,Allscripts, eClinicalWorks and HCare.

A lack of IT resources is also impacting nursing productivity.

· 93% of nurses in for-profit facilities stated they do not have computers in each room or hand-held/mobile devices to aid in the EHR requirements. 91% state they have difficulty even locating an available EHR workstation on wheels at their for-profit hospital job which, in turn, takes time away from patient care. 35% of nurses in not-for-profit hospitals have a similar situation of not enough devices.

· Within for-profit hospital facilities, just 15% of the surveyed nurse respondents believed the IT department that supports the EHR are knowledgeable and receptive to nurses’ suggestions in improving electronic documentation.

· Among those hospitals outsourcing the EHR help desk, 88% of nurses reported that their experiences with EHR’s call center do not meet their expectations of communication skills and knowledge of product. 98% of those directed to offshore help desks report their EHR problems being typically unresolved and that suggestions for improvement were never given consideration.

"Nurses will drive a new wave of inpatient EHR replacements and advances to outdated hybrid systems as it becomes harder to retain and recruit staff,” said Brown. “Hospitals, particularly in competitive markets, will experience an exodus of nurses who will change employers for those with flexible, highly usable EHRs, where nurses feel they can get more real time to care of patients.”

· Current users ranked Cerner as the most nurse user-friendly inpatient EHR vendor, particularly in interoperability with ancillary and physician EHRs. Other vendors in the study included: Siemens, McKesson, Epic Systems,Allscripts, CPSI, GE Healthcare, NextGen, Meditech, Quadramed, HMS, HCS, RazorInsights, 3M, HCare, Vista,Healthland, Prognocis and eClinicalWorks.

· 67% of nurses reported they have been taught workarounds to allow other health team members to view pertinent information related to a patient, as to not lower the quality of care, yet avoiding the EHR systems’ unresolved flaws.

· Among the EHR vendors ranked lowest in nursing satisfaction, 89% of nurses report developing creative workarounds to deal with shortcomings and system deficiencies that are not addressed or corrected after reporting issues to IT and nursing supervisors".

Frankly I was shocked and discouraged to read these statistics. It really raises some critical concerns on the effect of these systems on the workflow of nurses. The workflow tools discussed in the AHRQ are really important to use for addressing these critical issues.   I think Brown's earlier statement speaks to the root of the problem. “The meaningful use financial incentives for hospitals have many IT departments scurrying to implement these EHR’s without consulting direct care nurses, according to the majority of those polled by Black Book.” As we discussed earlier in the course, the involvement of nurses is essential in all phases of the SDLC. It seems to me that the lack of involvement of nurses not only contributes to implementation and acceptance issues, their non-involvement may be comprising the nurse-patient relationship and the quality and safety of care. I hope organizational leaders recognize very quickly the need to involve nurses and exploring and addressing their concerns is essential. Clearly the effect of Health IT systems on the workflow of nurses and patient care need to be addressed. 

Thanks for your thoughtful post, Dr. Reilly