Doctors should consider nurse, staff workflow when picking EHR

Physicians shopping for an electronic health record system likely will be told by consultants that they need one that will match their work flow. But often, technology experts say, a system designed to ensure a smooth flow for doctors doesn’t always work as well for others on staff, particularly nurses.

To keep things running smoothly, the EHR needs to meet the needs of all who will be using it to document care. Experts say that can happen if all users are involved in the selection, implementation and ongoing customization of the system.

John Kulin, DO, CEO of the Urgent Care Group in Manahawkin, N.J., said his practice has always involved nurses in EHR decision-making, but the level of involvement has increased significantly over the past two years as the practice moves toward team-based care. This approach is a change many health care organizations are making as care models such as patient-centered medical homes become more widely adopted.

These models of care rely on an EHR system that fits within the work flow of every team member who has to document an aspect of patient care, and gives each user the ability to see what others have done and how it fits within the overall care plan. Practice experts said physicians can benefit from others’ input on systems because, in the end, doctors will be rewarded or penalized based on what everyone in the practice is doing.

LuAnn Kimker, RN, principal consultant with the technology consulting firm Arcadia Solutions, said she has worked with many EHR systems, from homegrown solutions to products developed by large technology firms. They all had one thing in common, she said. “They were designed by and for physicians mostly to facilitate billing processes more than they were for documentation and improving care and outcomes,” she said. Improvements have been made in the past few years, but most systems still aren’t designed with the nursing or support staff in mind, she added.

One major issue is the inability for nurses to follow up on some physician orders in a streamlined way, Kimker said. For example, if a physician orders an injectable that will be given inside the office, the nurse must document where that injection was given, why it was given, and the patient’s response to it, which is a different process than a prescription that is sent to a pharmacy. This documentation can happen in one of two places: the medication list or the procedure section. Kimker said the medication list is usually used for prescriptions sent to the pharmacy, but the procedure section isn’t normally used for medications.

“It makes the challenge of work flow even more complicated,” she said.

Dr. Kulin said a problem he has had with multiple EHR systems is their inability to clearly show who entered what information. The system he adopted about a year and a half ago allows staff members to see when and by whom certain information was entered and allows the user to then “pass” the file along for the next step in the patient encounter.

Implementation tips

It’s important to start any implementation project by bringing together all employees whose work flow will be affected by the EHR, said Bill Fera, MD, chief medical officer and principal with the EY (formerly Ernst & Young) health care advisory practice.

All stakeholders should be brought together to form a steering committee, Dr. Fera added. All of them will be affected by the decision that is made “so all should have a say in what system is chosen, and there should be transparency as to why that system was chosen.”

Dr. Kulin said the team that helped with the implementation in his practice still meets once a month to go over needed changes as the practice continually works to bring patient wait times down. It’s a “constant project,” he said, which is why it was important to him to find an EHR that was easily customized. He has worked with systems that would take “close to an act of God to get something changed,” he said.

Dr. Fera said quality reporting and improvements should be considered when a practice examines work flow changes in the context of a new EHR system. “If viewed in this matter, it becomes quickly apparent that all disciplines need to weigh in on an [EHR] decision,” he said.

Kimker said these stakeholders will each play an increasingly important role as more practices adopt population health pay structures. “As the environment has changed, these needs have become greater,” she said.

Even though it’s early in the process of payment reform, Kimker said now is the time to address EHR work flow issues. New payment models will rely on good communication and the ability for everyone on the care team to know by looking at the medical record what was done and by whom, and how it relates to that patient’s total care.

It’s important to take care of this now, Kimker said. “When [payment reform] does come around, you’ll be well-positioned to take it on.”