McKenna Hughes and Karen Whitt, College of Nursing
Introduction
Previous research has correlated electronic health record (EHR) use with adverse patient events. While EHRs can improve patient safety due to enhanced legibility of patient records, reduced duplication, expanded access, and availability of clinical decision support reminders, if they are not configured and utilized correctly, errors can threaten patient safety. The safe use of EHRs is only as good as the interaction between the healthcare provider and the computer. Inadequate human-computer interaction can actually create patient safety issues. In response to these issues, the US Office of the National Coordinator for Health Information Technology developed the SAFER guides so that healthcare providers can evaluate EHRs’ use and safety features. During the course of nursing school, students are exposed to a variety of clinical practice settings and have experience with many different EHR products. Few studies have evaluated graduate and undergraduate nursing student clinical experiences with electronic health records. The purpose of this project was to evaluate undergraduate and graduate nursing students’ awareness of safe EHR practices while utilizing the SAFER guide checklists.
Methodology
BYU undergraduate and graduate nursing students filled out a 23-item demographic questionnaire that asked for responses regarding age, gender, education, clinical practice setting, years of clinical experience and experience with EHRs, and the number of hours spent per shift using and searching the EHR. The students were also asked to rate their personal attitudes towards EHRs on a 5-point scale including how the EHR affected productivity, job satisfaction, and patient outcomes. The SAFER guide checklist asked students to rate how well their EHR implemented certain features on a 3-point scale that included “fully implemented,” “partially implemented,” and “not implemented.” The open-ended questions included the following: 1) Have you experienced problems in the past with EHRs? 2)What did you learn about EHR safety from completing the SAFER guide checklist? 3) Please share your comments regarding the SAFER guide checklist. Permission to conduct this study was obtained from the University’s Institutional Review Board. Students were informed that participation in the study was anonymous and would not impact their course grade.
Results
The sample included 108 undergraduate nursing students with an average age of 23 enrolled in a senior capstone clinical practicum course. The students worked in over 15 different hospitals in 11 different specialty units. The students reported using 13 different EHR products. The study also included a sample of 37 graduate family nurse practitioner students who ranged in age from 25-49 years. The students reported a mean of 5.2 years of experience using EHRs and reported spending an average of 3.3 hours per 12 hour shift using or searching the EHR. These students worked in a variety of ambulatory/outpatient settings. The majority worked in family practice settings with an average of 13 providers in the practice. Both the graduate and undergraduate students were asked a series of yes/no questions regarding their experience and opinions about EHRs. Opinions varied regarding the question if EHRs contribute to adverse patient outcomes, with 50% of undergraduate and 60% of graduate students answering “yes” that EHRs contribute to adverse patient outcomes. The majority of both undergraduate and graduate students experienced problems in the past with EHRs, such as difficulty finding information. There were also several areas on the SAFER guide checklist that indicated features in the EHR were not fully implemented. For example, the item regarding “Urgent clinical information being recorded in the EHR and delivered to clinicians in a timely manner,” was rated as partially implemented by over 50% of the students. Also, most of the students rated that “Necessary information for referral and consult” and ability for “Clinicians to look up the status of electronic communications,” as only partially implemented. The following six areas outlined on the checklist indicate items that the students rated “not implemented:” 1) Mechanisms exist to monitor the timeliness of responses to messages, 2) Clear identification of clinicians who are responsible for action or follow-up, 3) Displays time sensitive and time critical information, 4) Contains a copy of clinician to clinician communications, 5) Indicates the urgency of messages, 5) Clinicians can access current patient and clinician contact information. Finally, the students were asked if they learned anything by completing the SAFER guides and the majority of the students answered “yes” that they had learned something about EHR safety by completing the guides. In response to the open-ended questions, the undergraduate students felt they “didn’t know much about the EHR system” and “needed to get to know all of the capabilities it can have.” The survey opened the students’ “eyes as to what should be in place in the EHR system, but sometimes isn’t.” The graduate students realized the “questions they should be asking regarding the safety of the EHRs they have been using in the clinical setting.” They learned that “many safety checks are vital to keep patients safe and help the healthcare workers provide safe care.” We have prepared and presented these results for a national webinar for American Nursing Informatics Association as well as the College of Nursing Scholarly Works Conference. Our abstract was also accepted for a podium presentation at the American Nursing Informatics Association national meeting in April 2016.
Discussion
This is the only study that has evaluated undergraduate and graduate students’ opinions regarding EHRs. This study has several limitations including the small sample size of the graduate students. The sample was also drawn from one university and reflects student opinions rather than those of practicing clinicians, who interact with the EHRs most often. Additionally, the students used a variety of EHR products, which doesn’t show how well individual EHRs work in the clinical setting. However, our data does provide a preview of overall EHR trends, which can be helpful in designing EHR systems as well as training students and healthcare staff who utilize EHRs.
Conclusion
Our study found that using the SAFER guides to analyze EHRs exposed several features that are not fully implemented to provide the utmost safety for patients. Most of these features relate to documenting follow-up messages and tracking clinician communication. Students reported that using the SAFER guide checklist increased their understanding about EHRs and allowed them to know what a safe EHR is capable of doing. A well-configured EHR system, however, is no substitute for effective communication—more training needs to be conducted so that clinicians know how to effectively communicate and document patient care to promote the best patient safety.