Electronic health records (EHR) and other Health Information Technology (Health IT) have certain benefits but have also been cited as burdensome and are often a stress point for nursing practice. The health record documentation experience for nurses may be time-consuming, require redundant entries, or be confusing to navigate, adding to frustrations (1, 2). Some things organizations can do to improve EHR experiences are:
- Reduce redundant entries, keystrokes, clicks, pop-ups, log-in requirements, and unnecessary documentation (1, 3).
- Include direct-care staff in decisions regarding redesigning and implementing technologies impacting their practice and patient care areas (1, 2, 3).
- Clean up user interfaces to remove ‘visual clutter’ (1).
- Improve interoperability between platforms for consistent and timely information exchange and eliminate repetitive tasks (1, 4).
- Assess opportunities to utilize clinical assistants or non-clinical staff to perform documentation work (1, 2, 5).
- Account for documentation time when scheduling to reduce note-taking pressure (1, 2, 5).
- Invite all stakeholders to inventory the needs of current documentation and risk mitigation requirements and eliminate non-value-added tasks and policies that add unnecessary documentation burden (1, 2, 3, 6).
- Establish a patient-centered/user-centered design principle to guide decisions for accessibility, workflow, and use of current and emerging Health IT (1, 2, 3, 6).
- Evaluate unit-time cost of documentation requirements to identify where documentation time can be shaved by altering a collection mechanism (typing, dropdown selections, VR, etc.) (1).
- Increase efficiencies by adopting technical solutions such as badge scans or biometrics for usernames and passwords, voice recognition software for patient documentation, and auto-population of screening/test results (1).
- National Academies of Sciences, Engineering, and Medicine, National Academy of Medicine, & Well-Being, C. O. S. A. T. I. P. C. B. S. C. (2020). Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being (1st ed.). National Academies Press.
- Michel, L., Waelli, M., Allen, D., & Minvielle, E. (2017). The content and meaning of administrative work: a qualitative study of nursing practices. Journal of Advanced Nursing, 73(9), 2179–2190. https://doi.org/10.1111/jan.13294
- Sinsky, C., A., Basch, P., Brown, M., T., & et al. (2018, August 30). Electronic Health Record Optimization: Strategies to help organizations maximize benefits and minimize burdens. AMA STEPS Forward. https://edhub.ama-assn.org/steps-forward/module/2702761
- Erickson, S. M., Rockwern, B., Koltov, M., & McLean, R. M. (2017). Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Annals of Internal Medicine, 166(9), 659. https://doi.org/10.7326/m16-2697
- Bergey, M. R., Goldsack, J. C., & Robinson, E. J. (2019). Invisible work and changing roles: Health information technology implementation and reorganization of work practices for the inpatient nursing team. Social Science &Amp; Medicine, 235, 112387. https://doi.org/10.1016/j.socscimed.2019.112387
- Kohl, R., Calderon, K., Daly, S., & Hanson, C. (n.d.). Reducing Administrative Burden: Refocusing on Patient-Centric Care. TMF Health Quality Institute. https://www.tafp.org/Media/Default/Downloads/practice-resources/TMF-admin-burden.pdf