Since our hospital adopted a new computerized record system, we nurses have been struggling to keep our focus on what was once considered nursing.
“I am here to administer pain medication to my post-op surgical patient in a timely fashion because that is my duty and my patient’s right!” wrote one nurse who works on the surgical telemetry unit.
“When I say timely fashion, I don’t mean: 1. When the doctor has a free minute to put the medication in the computer, 2. So the pharmacy can spend 5-10 minutes putting it in the computer, 3. So I can now acknowledge the medication once it is in the computer, 4. And then acknowledge it again on the eMar, 5. And then notice that the order was put in incorrectly by the doctor, 6. Who I then have to page and wait to call me back, who will then say, ‘can you just put it in, please?’”
McLaren Macomb Hospital, where I work, purchased and implemented McKesson’s Paragon computer system in the fall of 2009.
We’re not alone: hospitals across the country are adding electronic medical record (EMR) systems, spurred by incentives and penalties in the Health Information Technology for Economic and Clinical Health Act (HITECH), enacted as part of the 2009 federal stimulus.
The act provides financial incentives to purchase and implement this type of technology, laid out in a timetable of stages. And from 2015 onwards, penalties—in the form of reduced Medicare and Medicaid reimbursements—are likely to be levied on providers who do not meet the timetable.
The trouble is, these systems are getting in the way of the fundamental work nurses do.
Not an Exact Science
There is probably not a human being on earth who will not, at some time during his life, become ill and require health care. On the front line of delivery of that care is a very special person called a nurse.
Nurses assess illness and develop a plan of care—with the goals of improving health, alleviating suffering, and educating and empowering patients to lead healthier, happier, and more meaningful lives.
What we do is not an exact science. The endeavor requires more than just intellect. It demands keen observational skills, intuition, dedication, patience, introspection, objectivity—and perhaps most of all, the focused intent of loving compassion.
We didn’t go into nursing in order to fill in contextual menus to comply with reimbursement requirements.
“Contemporary EMRs are notoriously unusable,” wrote nurse Jared Sinclair in a 2010 article on the KevinMD.com physician blog. “All EMRs are clearly designed by programmers with no understanding of nursing care. Their software is written at the behest of healthcare administrators whose primary concerns are compliance and cost. Workflow efficiency comes last, if it comes at all.
“Contemporary EMRs are only contemporary insofar as they are being sold in 2010. As far as the technology they leverage is concerned, they are relics of the 1990’s (or worse).”
Companies like Apple and Nintendo have done far better than EMR technology, Sinclair points out, and have refined their applications and made them user-friendly. Could there be something wrong with the priorities of a country that uses its most advanced software technologies to develop games, rather than save lives?
During our current contract negotiations, our union, Office and Professional Employees Local 40, asked nurses to share our experiences with the EMR system. (We assured anonymity so that management could not identify us individually.)
An emergency room nurse described her frustrating experience trying to accurately document a dose of heparin, a blood thinner for patients with chest pain. “The doctor stated he wanted 4000 units bolus [all at once] and then a 1000 unit per hour infusion,” she wrote. “The order in Paragon stated 5000 units of heparin. I was given the option to decrease the dose, which I manually changed.
“However, I had to pick a reason why I decreased the dose. There was a drop-down box, and the only option was ‘Insulin decreased per protocol.’”
The drug was heparin, not insulin. What was she supposed to do? “I contacted the pharmacy and spoke to three different people, and the final response was, ‘snapshot the screen and give it to your manager.’ This was a nine-minute conversation.”
The manager finally advised her to select the given option for insulin, then separately document that heparin, not insulin, was given.
That’s nine extra minutes away from the bedside, just to document one medication—and to document it inaccurately, to boot. Multiply that times the many different tasks and patients a nurse juggles every day, and you start to see the problem.
Let’s Be Reasonable
In spite of the difficulties Paragon presents to the nursing staff at McLaren Macomb Hospital, our union is not totally opposed to the use of EMR.
After all, the federal government enacted HITECH in response to skyrocketing health care costs, massive columns of paper medical records, health care billing fraud, breakdowns in communication, and general administrative inefficiency.
We do understand the need for a comprehensive system of EMR to reduce the number of medical errors, to make patient information available simultaneously to collaborating providers, to reduce data storage problems, and all the other benefits that EMR can offer.
However, our nurses do not want to become lost in the land of acronyms, drop-down menus, non-existing options, and endless grey pages in which endless boxes must be clicked.
The nurses of OPEIU Local 40, and those of all McLaren facilities, want our leaders to recognize that the McKesson Paragon platform does not adequately or effectively meet our clinical needs. We want them to replace it with one that fulfills both the legal compliance needs and the needs of the patients who are hospitalized for competent, attentive, and effective nursing care.
We’re in nursing because people are still being born, still getting sick, and still dying. And that isn’t going to change anytime soon, no matter who is in charge.
New from Labor Notes: The Steward’s Toolbox is a how-to resource guide that gives labor activists the skills and orientation they need. Pick up a copy today!