A Key Missing Element of EHRs
Nurses play a key — if not crucial — role in successful hospital EHR implementations.
- They are the first people that frustrated physicians complain to and often have to deal with borderline or actual abusive commentary or language emanating from an angry physician.
- They are often the initial super-users who can show physicians how to navigate through specified workflows that they may not have absorbed during EHR training (if they attended training sessions at all).
- They often have to enter orders or deal with verbal orders given by a physician who cannot (or does not want to) enter orders by Computerized Provider Order Entry processes (CPOE – please note use of the term “Provider” and not “Physician,” which is the true appropriate use of the acronym CPOE.)
- They are often the first users in the go-live schedules for clinical documentation.
In spite of their key role in patient care, by tradition (in both paper and electronic worlds), their clinical notes are almost universally unread by physicians. In spite of being the caregivers who spend far more time at the bedside than any other clinicians, their notes are either ignored, or at best casually reviewed by physicians.
As a result, both the paper and electronic environments are often replete with documentation contradictions with inaccurate information entered by either the physician or the nurse, or with information that conflicts with patient status. After cataract surgery, a nurse might enter “Pupils Equally Round and Reactive to Light and Accommodation (PERRLA) when one pupil is pharmacologically dilated or constricted, or a physician might document “Patient fully ambulatory and stable” when the patient is in fact unable to get out of bed or has had fluctuating vital signs. The number of possible conflicting entries is both unlimited and endemic.
This is where standard vocabulary becomes as important as accurate clinical observations. An EHR functionality that has been lacking since the early years of clinical information system design has been the ability to cross reference nursing and physician clinical documentation notes and to generate alerts when contradictions are present. This is not only of essential importance to patient care, but to reducing vulnerability to medical liability.