It’s Not Like Pages in a Book: Changing Nurses’ Perception of Electronic Health Records

by Michelle C. Danda MN MPN RN CPMHN(C)

Citation: Danda, M.C. (2021). It’s Not Like Pages in a Book: Changing Nurses’ Perception of Electronic Health Record. Canadian Journal of Nursing Informatics, 16(3-4).  https://cjni.net/journal/?p=9386

The Covid-19 pandemic has changed healthcare. Technological solutions to problems like accessibility, collaboration of geographically separated care teams, and timely wide-spread tracking of infectious disease testing are only a few of the progressive lasting changes in an everchanging healthcare system. Rapid uptake of computer-based technology is challenging nurses to understand the benefits and risks of implementation and adoption of digital technologies to support healthcare practice. Health informatics is an emerging area that nurses are well positioned to lead if resources are allocated to the planning and implementation of education and professional development strategies to support nurses’ expertise with Electronic Health Record (EHR). Nurses must embrace EHR as an integral tool to deliver, research, and improve healthcare services, in turn embracing health informatics as an essential component of nursing care.

When I began my nursing career in 2008, computers were already part of nursing practice. Back then limited applications were accessed in day-to-day care primarily to view lab results and confirm the client identifiers recorded in the electronic system; nursing assessments, and medications were still documented on paper. Today EHRs are used to support medication administration, a multitude of nursing assessments, and can assist in clinical decision-making processes. The benefits of using an EHR include timely access to patient information, quick communication of lab and diagnostic results, and increased collaborations with patients and other healthcare providers.

My first taste of clinical informatics happened in 2018 when I volunteered to be a Peer Mentor in a large Clinical and Systems Transformation project in the Lower Mainland, British Columbia. My experience was career changing. I was exposed to perspectives of nursing work that opened my eyes to the power of EHR in changing nursing practice. But, at first, I struggled with understanding the significant impacts, and the implications of a shift to EHRs had on nurses’ roles and their relationship with clinical documentation in day-to-day practice.

The shift to EHRs was much more than learning how to use a computer program. I was baffled by the amount of required training on detailed workflows of members of the clinical team. Wasn’t this just an electronic version of a paper chart? How hard could it be to use a computer program? The Clinical Informatics Nurse who taught me the workflows recognized my lack of understanding, simply explaining, “You are approaching this like it’s pages in a book, but the system is designed to do more than that”. I needed time to cognitively process that the EHR is not simply an electronic repository of information, it is not akin to an ebook or a PDF scan of the paper chart. EHRs are interactive tools that support clinical care and promote collaboration, while also capturing health information. The future of healthcare depends on nurses making a conceptual shift to understand EHRs as dynamic tools, not passive information repositories.

The analogy shifted my understanding of the larger clinical and systems changes necessary for successful adoption of EHRs. Back then I had limited knowledge about health informatics, and concepts like user-centered design. I was having difficulties seeing an electronic format beyond my knowledge of computer programs like Microsoft Word. I viewed EHR as a static entity that lived in one place and time, and was added to as necessary, but locked in a single paper format. The difference between my understanding then and now reflects my transformative learning experience. EHRs are like a set of tools that will change nurse practice. Nurses must embrace EHRs as powerful tools that can be used to foreground nursing practices that improve individual patient outcomes while enabling optimal functioning of the healthcare system.

The discipline of nursing can be powerful in changing the healthcare system. But, nurses must take lead roles in developing the electronic clinical systems to ensure thoughtful design that is created, implemented and evaluated by nurses. Nurses’ concerns about issues like privacy, one size fits all standardized care, and surveillance to monitor individual nurse practice substantiate the need for nurses to be key stakeholders in EHR policy planning, design and evaluation.

Clinical systems enhance care. They support collecting information, adoption of outcome measures to inform quality improvement, and help in establishing minimum reporting standards to ensure the healthcare system is doing what it is supposed to be doing – supporting health. A well designed EHR can be used to create a patient-centered system that supports optimal patient care, and also illuminates hidden nursing practices that are integral to the optimal functioning of the healthcare system but have not previously been identified as such. The tidal waves of change in adoption of EHR leads to a vast new healthcare world in which nurses can emerge as systems leaders by embracing health informatics.