Nursing student experiences regarding safe use of electronic health records: A pilot study of the SAFER guides

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PI: Karen Whitt
Co-PI’s: Katreena Merrill, and Lacey Eden

Evaluation of Objectives

The purpose of this project was to mentor undergraduate nursing students through the entire research process while they worked on a study to evaluate undergraduate and graduate nursing students’ and practicing nurse practitioners’ clinical experience and awareness of safe electronic health record (EHR) practices utilizing the SAFER guide checklists. This project provided multiple mentoring and learning opportunities for the undergraduate students who worked on this project. We exceeded the original objectives of the study and included more opportunities for student research mentoring than were listed in the original proposal. The students had the opportunity for hands-on experience with all aspects of the research process, which included opportunities to collect data, analyze data, present findings at national nursing conferences, publish articles, participate on EHR safety panels, present study findings to the Office of the National Coordinator of Health IT, and directly see how research influences policy. Additionally, undergraduate and graduate nursing students who participated in the project learned about EHR safety which was valuable in their future nursing practice.

This study was important because if EHRs are not configured and utilized correctly, errors and omissions may occur that jeopardize patient safety. Previous research has linked improper EHR configuration and use with adverse patient events. There are currently over 300 different EHR products on the US market and there is a lack of consistency among these various products. In response to this problem, the US Office of the National Coordinator for Health Information Technology (ONC) developed the Safety and Assurance Factors for EHR Resilience (SAFER) guides to allow healthcare providers to evaluate EHRs for optimal use and safety features. During the course of their education, nursing students are exposed to a variety of clinical practice settings and EHR products. Few if any studies have evaluated graduate and undergraduate nursing students’ experience and awareness of safe EHR practices.

Project Findings

We evaluated awareness of safe EHR practices among 108 BSN and 51 FNP nursing students enrolled in clinical practicum courses at BYU. Students completed a demographic survey and evaluated the EHR used in their clinical site by completing one of the SAFER guide checklists. FNP students used the computerized provider order entry (CPOE) guide and BSN students used the clinician communication guide to rate if certain items in the EHR were “Fully implemented,” “Partially implemented,” or “Not implemented.” Over 80% of the BSN and 60% of the FNP students reported that they experienced user problems with EHRs in the past. Over 50% of BSN and 60% of FNP students answered “yes” that EHRs contribute to adverse patient outcomes. The majority of BSN students rated several areas relating to clinician communication as not implemented in the EHR including: Monitoring the timeliness of response to messages and identification of clinicians responsible for follow-up. Likewise, a number of areas related to CPOE were rated as not implemented by the majority of the FNP students including: Drug-patient age checking and dose-range checking. Nursing students reported that many of the features assessed by the SAFER guides were not fully implemented in the EHR they were using. These findings highlight areas in which EHRs can be improved to optimize patient safety. The majority of students reported that utilizing the SAFER guide increased their understanding about EHR features. Utilizing the SAFER guide checklist identified areas to improve EHR safety and informatics education.

We also evaluated 431 nurse practitioners’ experiences with EHRs used in their current clinical practice. Nurse practitioners who attended the American Association of Nurse Practitioners (AANP) 2015 annual meeting in New Orleans were asked to complete a brief demographic survey, the Computerized Provider Order Entry SAFER guide checklist, and a questionnaire that rated satisfaction and comfort with EHRs, as well as, the impact EHRs had on productivity, job satisfaction, patient care, and adverse patient outcomes on a 5-point Likert scale. Nurse practitioners were also asked open ended questions to describe any problems that they experienced in the past with EHRs. Only 27% of the participants agreed that information was easy to find in their current EHR and 34.4% agreed that EHRs contribute to adverse patient outcomes. Over 75% of the participants reported that they experienced problems in the past with EHRs. Many participants shared narrative experiences about the specific problems encountered with their current EHR system. Problems with time management, information discrepancies, server problems, and documentation errors were some of the common EHR problems described by the participants.

We also evaluated utilization of pharmacogenomics and availability of clinical decision support for prescribing medications among the 431 nurse practitioners that completed our survey at the AANP annual meeting. We found that very few EHR systems have clinical decision support related to pharmacogenomics and that nurse practitioners have limited knowledge of pharmacogenomics. Very few of the nurse practitioners surveyed utilized pharmacogenomics for prescribing in their clinical practice.

Evaluation of Mentoring Environment

Students had the opportunity to work one-on-one with faculty mentors which allowed for development of life-long professional and personal relationships. Six of the students that worked on this project have graduated. All six have been successful in finding employment and stated that having this experience on their resume set them apart from other candidates. One student was accepted to a prestigious graduate nursing program after graduation from the BYU College of Nursing and says that participation in this project helped him in his application for graduate school. Another student was accepted into a prestigious nurse residency program in critical care nursing and said that having this research experience distinguished her from other candidates. These examples illustrate how participation in this project fit with the mission of BYU to assist individuals in their quest for perfection and eternal life. Participation in the project was spiritually strengthening, intellectually enlarging, character building, and lead to lifelong learning and service.

Students who participated in this study were mentored in aspects of the research process including survey design, data collection, analysis and dissemination of research findings. The mentored students participated in the following opportunities while working on this study.

  • Several students helped to research current literature and brainstorm to design the demographic survey that was utilized in this study. The survey was effective for the purposes of the study and we have received requests from researchers at other universities to utilize our survey after we published and presented our findings.
  • One student helped to collect data from 108 undergraduate and 51 graduate students. This student also entered the data in Excel and then learned how to transfer and organize the data in SPSS for analysis. This student also helped with the analysis of qualitative data collected from open-ended questions.
  • Two students had the opportunity to collect data from practicing nurse practitioners at the American Association for Nurse Practitioners (AANP) 2015 annual conference in New Orleans. Students collected survey data from 431 practicing nurse practitioners who attended this conference. This allowed the students to have first-hand experience with the challenges of data collection. The PI attended this event with the students and was able to mentor and teach about the data collection process. Additionally, the students were able to interact with the nurse practitioners who attended the conference and learn about the nurse practitioner role. This ignited the students’ interest and enthusiasm for pursuing a graduate degree in the future.
  • One student entered the data collected at the AANP conference into an Excel spreadsheet and participated in the data analysis. This student also had the opportunity to analyze responses to qualitative questions.
  • Students had the opportunity to collaborate with Dr. Laverne Perlie, Senior Nurse Consultant for the Office of the National Coordinator of Health IT. This was an opportunity to interact with the federal government organization that creates policy for health information technology in the US. The ONC collaborated with Dr. Whitt and the BYU students to conduct the pilot study of the SAFER guide checklists. BYU College of Nursing was the first program to identify and participate in this important research project. The ONC was pleased with this project and expressed the desire to continue collaboration on future research.
  • Three students presented findings from our study at the BYU College of Nursing annual Scholarly Works Conference in Fall 2015.
  • One student helped to prepare an abstract and presented findings with the PI at the Summer Institute of Nursing Informatics annual conference 2016 in Baltimore, MD.
  • One student prepared an abstract and presented findings with the PI at the American Nursing Informatics Annual conference in San Francisco in April 2016.
  • One student prepared an abstract that was presented by the PI at the American College of Medical Genetics annual meeting in Tampa, Florida in March 2016. This student helped to analyze several specific questions related to utilization of pharmacogenomics and clinical decision support in EHRs that were part of the survey data that was collected from the AANP conference.
  • Students had the opportunity to prepare and present findings from this study at two national webinars sponsored by the American Nursing Informatics Association (ANIA) and the Office of the National Coordinator of Health Information Technology (ONC). These webinars were offered for CEU credit and are posted on the ONC and ANIA websites.
  • Three students worked with the PI on writing and publishing journal articles. One journal article was published in August 2016. Two other articles have been submitted for publication and are currently in review. This project continues to generate manuscripts and there are two other articles that are being developed for publication in the future that will include students who worked on the project as authors.

List of students who participated and contributions

  • Chalese Adams: Data collection and entry
  • David Adams: Data collection and entry
  • Lindsay Dixon: Data collection at AANP conference, data entry, data analysis, presentation and publication.
  • McKenna Hughes: Survey design, undergraduate data collection and analysis, presentations, and publication
  • Haley Fellows: Data collection at AANP, presentation.
  • Kelsie Pead: Survey design
  • Hyrum Wright: Data analysis, presentation, publication

Academic deliverables

The following presentations were a result of this project (Student names are in bold):

  • Whitt, K. J., Eden, L., Merrill, K. & Hughes, M. (2016, December 8). SAFER guide implementation: Nursing student experience pilot study. Office of the National Coordinator of Health IT Clinical Informatics Grand Rounds sponsored by Office of Clinical Quality and Safety, CEU and CME Webinar.
  • Whitt, K. J., Wright, H., & O’Brien, T. (2016, September, 15). Nurse practitioners’ use of pharmacogenetics in clinical practice. Abstract of distinction and top-rated podium presentation at the Council for the Advancement of Nursing Science, State of the Science Congress on Nursing Research. Washington, DC.
  • Whitt, K. J., & Dixon, L. (2016, July 20). Electronic Health Records and Patient Safety: Nurse Practitioners’ Experiences in Clinical Practice. SINI 2016 26th Summer Institute in Nursing Informatics, Baltimore, MD
  • Whitt, K.J., Merrill, K., Eden, L. & Hughes, M. (April, 2016). Nursing students’ assessment of EHR safety utilizing the clinician communication and computerized provider order entry SAFER guides. American Nursing Informatics Association Annual Meeting. San Francisco, CA.
  • Whitt, K.J., O’Brien, T. & Wright, H.A. (March, 2016). Utilization of pharmacogenetic profiles as a basis for prescribing by nurse practitioners. American College of Medical Genetics Annual Meeting. Tampa, FL
  • Whitt, K. J., Dixon, L., Hughes, M., & Fellows, H. (2015, October 19). Too many clicks: Nurse practitioners’ ratings of EHRs and patient safety. BYU College of Nursing Annual Scholarly Works Conference, Provo, UT.  Whitt, K. J., Eden, L., Merrill, K. & Hughes, M. (2015, June). NP and BSN students using the clinician communication and computerized provider order entry SAFER guides in the acute care and ambulatory settings. National CEU Webinar for American Nursing Informatics Association.

The following publications are a result of this project (Student names are in bold):

  • Whitt, K. J., Hughes, M., Eden, L., & Merrill, K. (2016). Nursing student experiences regarding safe use of electronic health records: A pilot study of the SAFER guides. CIN: Computers, Informatics, Nursing. doi: 10.1097/CIN.0000000000000291
  • Whitt, K. J., Dixon, L., & Cangelosi, P. (In Review). Too many clicks: Nurse practitioners’ experiences with EHRs and patient safety in clinical practice. Journal of the American Association of Nurse Practitioners.
  • Whitt, K. J., Wright, H., & O’Brien, T. (In Review) Nurse practitioners’ utilization and knowledge of pharmacogenomics for prescribing in clinical practice. The Pharmacogenomics Journal.

Budget

We are grateful for the funding from this MEG and feel that we fully accomplished the objectives of this study plus much more. The budget was used as follows:

Student Wages= $3000
Travel for students and faculty for data collection and presentation=$13,249.74
Conference registrations=$3002.80
Supplies=$654.09
Total expenditures=$19,906.63