by Julia Casey, BN RN CVAA(C),

Manager, Clinical Education Team

Citation: Casey, J. (2024). How I helped design an EMR and lived to tell the tale: A nurse’s adventures. Canadian Journal of Nursing Informatics, 19(4).  https://cjni.net/journal/?p=14011

Introduction

It is important to involve front-line staff in developing new EMR systems right from the start and throughout the design, development, and launch phases. This helps make sure the system addresses a wide range of needs and is built based on how it *will* be used, not just how it *should* be used. Too often, nurses are brought in too late to make real changes, which leads to systems that do not work well for nursing or patient care. That ends up causing workarounds, extra manual tasks, and frustration for everyone.

My goal was to design a system that, from the ground up, considered the complexity of medical orders, nursing and patient needs across different treatment types, and allowed flexibility for future growth and changes.

Background

I work for a national, privately owned infusion clinic company. I started as an infusion nurse 14 years ago and have since taken on various roles, including managing teams and overseeing clinics. After advocating for a new system for years, I was asked to join the project team as the clinical subject matter expert (SME).

We have been using an internally designed system for over a decade, but it’s become outdated, lacking integration capabilities, automation, and strong data collection features. Even though the need for a new system had been discussed for years, the project only got formal approval in early 2022.

The Project

The Role of Nurses in the Design Process

As the clinical SME for the project, I worked with the design team to explain how our processes and systems work, and alongside the Operational SME, we reviewed potential solutions and identified any gaps. We also made sure to get input from our nurses by asking for their feedback on different design decisions, like hardware setups in the clinics. This way, we avoided making assumptions about what they would prefer and helped build more buy-in for the new system.

From Concept to Implementation

We started by mapping out both our current processes and the future state we wanted.

Working closely with nurses and Regional Nurse Managers, I pushed for a few key system features:

• Standardized charting to avoid having different worksheets for each drug

• Automated notifications to physicians, patient support programs and pharmacies

• Just-in-time information display to reduce unnecessary searching

• Guided workflows and prompts for new nurses

• Automated document generation and transmission to reduce manual tasks and give nurses more time with patients

There were many challenges along the way:

• Designing a system that supports nurses in decision-making, with many drug programs all with different preferences, was very tricky.

• Budgets and project timelines meant constantly adjusting priorities for Release 1, balancing essential features with what could wait for later.

• Not all systems can be updated at once, so external system integration will have to come in future releases.

Lessons Learned and Future Recommendations

What we did right

• Resource planning: Management made sure I had a full-time team member to cover my workload so I could focus on design. We also communicated to the company that the Operational SME and I would be less available, offering alternate paths for support.

• Regular meetings: We held frequent internal and external meetings with the developer to address concerns and issues right away.

• Management buy-in: This project was a top priority for the company, regularly highlighted in company communications, town halls, and retreats.

• Change management and marketing support: Our marketing and change management teams helped build excitement, gather feedback, and keep future users engaged.

What We Could Have Done Better

• Plan for the human factor: Allow for PTO in the project schedule

• Have dedicated admin support: Have dedicated administration help sooner to manage scheduling and coordination.

• Have a ‘IT to Human’ translator: Our Business Analysts who worked with the SME team were crucial to helping us understand the impact of certain design choices as well as advocating for what we felt was very important in the first release, etc.

• Schedule time to do the work: Design can require many meetings, leaving no time to do offline tasks.  Plan for designated no-meeting days and consider shorter meetings. 

• Be clear on the details: Be very clear and vigilant about how the system will work in practice, down to the smallest details, like how many clicks it takes to get between sections or complete day-to-day documentation.

• Document decisions well: Use tools like call recordings and AI transcriptions to keep track of decisions, as it is easy to lose track over long periods of time.

Project Status

Although our new system is still in development, my experience with this project has made it clear that having an experienced nurse involved from the start was essential to creating a system that truly supports nurses rather than complicating their work.

Conclusion

Nurse-driven technology development makes a big difference by ensuring healthcare tools, like EMR systems, are built with real-world experience in mind. When nurses are involved, the systems end up being more practical and user-friendly, which helps both patient care and day-to-day workflows. Plus, it empowers nurses by recognizing their expertise and encouraging teamwork, setting the stage for future innovations that better support healthcare professionals and patients.