Electronic Health Records (EHR) Is the Future of Nursing
Electronic Health Records (EHR) are more than a repository of information. Health informatics requires nurses to break through the cognitive constraint of thinking about an EHR like a scanned paper document or a series of static saved Word documents akin to a static, unchanging paper chart. It’s not like pages in a book.
This year I turn 40. I do not even remember life without computers. My dad bought my family’s first computer when I was 6 years old. It was a Commodore. When I started Junior High in the early 1990s I was surfing the net using AOL to find research for my school projects. When I started university in the late 1990s registration already moved to an online system. Professors were rapidly embracing the use of PowerPoint to create their lecture presentations. When I started nursing school in 2006 Calgary Health Region had just gone live with its first EHR system. I don’t remember a time without computers. I barely remember a time without the Internet. And (I’ll write it again), I turn 40 this year. Nurses educated in Canada are entering post-secondary programs with computers in their pockets so powerful that they can do their banking, write a paper, and participate in a virtual lecture all at the same time. Technology is rapidly changing, and nurses must embrace this.
Again, I turn to the analogy of pages in a book and emphasize that EHR is not at all like pages in a book. And so, those of us who might remember paper documentation writing volumes of clinical documentation in a patient chart have to let go of this type of understanding of a physical chart. This was an analogy that a Clinical Nurse Informatics Specialist used with me to being explaining the necessary change that I needed to make in my understanding of a primarily written health record to an electronic modality.
A Change in Perspective
Way back when (in 2018) when I first became interested in EHRs and implementation strategies, I did not know much about informatics and user-centered design. I took a chance and volunteered to be a Peer Mentor at my worksite. Way back when, even with my experience in using other EHRs and providing education and being in the change-management process of different functionality in EHR I had difficulty conceptualizing an EHR beyond the applications I was familiar with. I was cognitively stuck.
EHR is not a static entity that functions like pages in a book. EHRs are not collections of data, chronologically ordered in one place, in a single moment in time. The difference between what I knew and what I know now are like night and day. Capturing a person’s health information using technology is centered on the use of multifunctional tools that are approaching a place of being ubiquitous in healthcare. They are approaching being ubiquitous in nursing care.
Many transformative learning experiences were necessary to reach the understanding I have today. The result of those experiences was revisioning and understanding of the EHR not as simply a repository of information, more than a static legal record to prove the things that I had done as a nurse, it is a tool that can be used for powerful transformational change in the healthcare system. And, with that acceptance must come letting go of understanding what is. Objective measures and scales are useful tools for capturing changes in a patient's situation. But, have we ever really been that great in terms of documentation that captures the patient's lived experience of diabetes, or an MI, or schizophrenia, or a broken arm, or a respiratory virus, or their journey within the continuum of care? The transparency, visibility, and accessibility of EHR can be a game-changer.
Perhaps this is the time that nurses advocate for the most effective strategies for including that once elusive concept of the "patient voice" in their health record. Healthcare clinicians are confronted with difficult questions about how close what we document in a patient's health record captures the patient voice; how close our is an interpretation of the patient's subjective experience of illness and wellness to what they are actually experiencing? And, is what we are capturing effective for communication and care for other clinicians, as well as for the patient and their families as the centre of care? We are charting new territory of co-creation of patient documentation, and wide-spread use of patient portals through which everyone can access their health information.
Change Management - Grief and Loss of What Once Was
I did know that things were changing. The format of narrative documentation was envisioned as a means of telling the story of their patient, bringing in their voice, and knowing them as a person. But, is that ever what narrative documentation was? Was it ever a tool used to engage with patients in a collaborative and caring way, or is that something that we hoped would happen?
Computer technology is increasingly present in our lives. Privacy issues abound with increased patient access and transparency of health records that seemed to be ever-bound under lock and key. A paper chart was something only accessible by a select few clinicians, clerical staff, and administrators who worked in a specific health service. In contrast, EHRs are visible to many clinicians who have access to a specific system. Certainly, issues of privacy and confidentiality must be addressed head-on, not ignored until a serious issue arises. But this represents a great new world to at nurses can emerge as leaders. Clinical systems are built on tracking, billing, outcome measures, and minimum reporting standards required to prove that we are doing what we are supposed to be doing. But it can be more. A well-designed EHR can be used to create a patient-centered system that supports and uncovers hidden nursing practices.
It is imperative that from a social justice perspective nurses broach issues of privacy and sharing of information. The fear of EHR as a surveillance tool can be one option, where monitoring of individual practice can be a legitimate fear. However, EHR with thoughtful design not just informed by Nurses, but led and driven by nurses and the discipline of nursing can be powerful in changing the healthcare system.
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