Documentation Burden

Recently, I have become aware of EHR documentation burden. This was raised at a clinical informatics meeting by frontline nurses who are members of this group. Since that time, I have come across articles, commentaries, and interviews with nursing leaders where this issue is mentioned. I have even found a 2009 document published by AHRQ entitled Impact of Health IT on Nurse's Time Spent on Direct Patient Care. Yes, nearly 10 years ago AHRQ anticipated this unintended consequence of EHRs. Last year Patient Safety Solutions published a blog "How Much Time Do We Actually Spend on the EMR?" This post reviewed recent studies measuring the time nurses and other clinicians spend documenting. One study by Higgins (2017) found that “Overall time in the EHR (documenting, reviewing, and medication preparation) of about 3 hours per 12-hour shift was corroborated by observations and the automatically generated computer time stamps.” I have to wonder, about the extensiveness of the unintended consequences for the clinicians and how much of the issue is related to how EHRs were implemented?  I know my organization has begun to examine this issue and the impact on our nurses at the bedside.

Moving forward as I scanned the literature, I found several health systems have attempted to address this issue through optimization projects. EHR vendors offer optimization services to assist their clients to address documentation burden. There is growing consensus that organizations created EHR screen builds that have nurses collecting all types of data and in some cases, the data capture isn't nursing related. For example, how does documenting a patients' belongs inventory inform nursing care or clinical decision-making? Are nurses the right person to collect this data? Additionally, as we create numerous queries, we often use unstructured homegrown data labels that contribute to the issue of interoperability. These data fields have unclear nonstandard data definitions. In our organization, we have created admission documentation demands that take nurses away from clinical care and require at least an hour to complete a single admission using nonstandard data field.

As I think more documentation burden, I am finding two components to consider: a) data capture and b) data foraging. Both, data capture (requirements for data recording) and data foraging (looking for the data you need to inform clinical decisions) contribute to documentation burden for nurses. On a positive note, organizations are beginning to create guidelines that can be used to evaluate if the data capture requested should or should not be included in the EHR for a nurse to spend clinical care time collecting.  I am reaching out to those organizations in hopes to learn more about the outcomes of their journeys.  Additionally, I have become aware that American Nursing Association and the Office of the National Coordinator have begun a project to explore this issue. 

EHRs were thought to help with information processing and clinical data sharing. The belief was that EHR would create usable data to support clinical activities and get the nurses back to bedside care.  Have we missed the mark? Anyone working on these issues? I hope to share our organization's journey, as we work to address the documentation burden we are attempting to overcome.  I invite you to share your experiences.  


References:

Higgins LW, Shovel JA, Bilderback AL, et al. Hospital Nurses' Work Activity in a Technology-Rich Environment: A Triangulated Quality Improvement Assessment. Journal of Nursing Care Quality 2017; Published July/September 10, 2017, 32.3 pages 208-217.