We started meeting with Epic in January 2022 – please weigh in!
January 2022 – Recently, using one of our MSNBC op-eds as a platform, we asked the makers of Epic charting software for a meeting to discuss how their widely-used software might become more nurse-friendly and use less of nurses’ precious clinical time. That would enable nurses to spend more time on direct patient care–including tasks the software itself records–as well as improve nurses’ sense of well-being and ability to advocate. Epic representatives graciously agreed to discuss this with us, and we have a meeting set for the middle of this month. We welcome your input. Our top areas of interest are:
- Developing voice recognition software, so that nurses can dictate their assessments and other interventions, which could save nurses many hours per shift.
- Creating a nurse report record or sheet, putting data nurses have entered during their shift into a useful format. Nurses could then refer to it while giving or getting report, instead of having key data isolated in small, widely dispersed digital boxes, leaving nurses to start from scratch with paper and pen to tell the story of the patient. We understand some health systems have enabled such nurse report records, but we believe this should be a standard feature of the charting software.
- Enabling the ability to copy and paste everything, including previous assessments, fall risks, restraint assessments and interventions, so nurses do not have to fill out the same boxes over and over and over again, wasting precious time that could go to patient care.
- Changing the word “orders” to “scripts,” to avoid giving physicians and others the mistaken impression that physician are in charge of nurses–or patients. (See more on this below.)
If you have suggestions as to changes you would like Epic to consider, please let us know by January 13, 2021 so we can include your thoughts in our meeting. Please email us your ideas at email@example.com. Thank you.
Regarding our request to end use of the term “orders” in the clinical setting
When physicians or other providers use the word “orders” to refer to their prescriptions, it encourages them and the public to believe that physicians are in charge of nurses and patients, and that whatever they “order” nurses must necessarily do. Physicians and other advanced providers can prescribe medicine and other treatments. But when physicians or other providers use the word “orders,” it encourages them and the public to believe that physicians are in charge of nurses and patients, and that whatever they “order” nurses must necessarily do. That is not so. Patients have the right to control their own health care. And nurses have the autonomy as well as the legal, professional and ethical obligation to undertake only care that they believe is in the patients’ best interests. Nurses should decline to implement prescriptions they reasonably believe are not safe, wise, or advantageous for the patient. Using the word prescription (or “script” for short) would remove the damaging word “order” from health care’s vocabulary. This change would better reflect the true relations among patients, nurses, and physicians, improving patient health and the health care workplace. Here is a recent example:
16 thoughts on “Could charting software be improved?”
Semantics, i.e., orders vs scripts, is not the problem. Workplace respect in all directions is the problem. Understanding patients’ rights, regardless of nomenclature, is the problem. Coming up with simplistic descriptions of serious problems is dangerous. This has been happening the entire 45 years I’ve been an RN. It is 2022 now. Time to stop.
Regarding “Enabling the ability to copy and paste everything”, this is even more dangerous. Nurses should “not have to fill out the same boxes over and over and over again, wasting precious time that could go to patient care.” Agreed. Again, the solution is not shortcuts or workarounds, but rather with policies. After several years as a nurse informaticist consultant, I witnessed countless policies not based on evidence, but instead on tradition or a sad but well-known refrain, i.e., “that’s the way we have always done it”. Re-examine why those boxes are required to be completed so often. Is it necessary? Is there a way to document no change since ‘xyz’ time from the same nurse documentation? There are many ways to solve this but the errors and clutter that come from copy-and-pasting leading to meaningless records do not further the cause of any patient a nurse is required to advocate for.
This is what physicians do multiple times each day – they chart “Reviewed chart from xx/xx/xxxx with no interval changes.” I see this every single day in surgery with H&P reviews that are required to proceed to the OR. Nurses should have the same streamlined ability, as you suggest.
The problem with policies is that they grow from intrusive oversight from now run-amuck organizations like TJC and HFAP. We are OVER active in developing policies to fit these payment rules (Let’s all remember that is exactly what they are). David’s definition of a policy: An opportunity to fail. So, yes, policy redesign is a great starting point – but EPIC is running in real-time and in need of solutions to meet current policies, overreaching though they may be.
Epic should start on a Kardex-like page that shows nurses what labs, dx tests, drugs etc are scheduled for the shift. Not a list of useless details about orders that have since expired. Time spent searching for relevant and timely procedures, drugs, labs to be drawn, etc. is wasted time.
It also needs to incorporate nursing knowledge of the patient’s unique needs. An example: I once got a man in the chair & he immediately passed out. I thought he was having a stroke. A nurse who knew the patient ran in and said, ” Oh, he always does that. Put his head down for a minute.” He was ok, but what if the nurse who knew him hadn’t walked by at that moment? Had this idiosyncracy been documented for me to see it, I would have known. There is no place to document such unique characteristics. This is nursing knowledge. We need to share it.
This is a great idea. Thank you so much for sharing it. We will include it
What about Cerner also They need more help the Epic from what I have been told by travel nurses
We fully agree, Kerry. We reached out to Cerner for a meeting and haven’t heard back, but we will try again after we’ve had our Epic meeting
I don’t understand why all of Epic’s reports and flowsheets are institution-specific. Lack of nationwide standardization makes work unnecessarily difficult for new and traveling staff.
You might consider reaching out to nurses at University or Colorado Hospital. That system has its flaws, but while I was working there, the nurses created “Project Happy”, a hospital committee that worked with Epic to carry out a major flowsheet overhaul. It was efficient, intuitive, and LIFE CHANGING– saved me probably 30mins a shift. We began charting assessments fully by exception (WDL values should not even be an option imo; they should auto-populate on the back end), and there was a way to chart “no change from my previous assessment; exceptions noted below” instead of copying and pasting. Charting education and care plan was still not well integrated, but it was a huge step forward (not to mention Epic-pump/device integration). I now work at another top hospital with plenty of $$ and am shocked by how antiquated their Epic flowsheets are.
This is a great information. Thank you for sharing. I wish I had found this site before the deadline. I hope all went well with Epic. I am on a team working on the med reconciliation process but it is one piece of a very large issue. It seems we are continuously “tweaking” based upon what someone experienced somewhere else.
Nice work on the site Sandy! Don’t know if you remember me but we worked together in the ED at Georgetown.
Hi Regina, good to hear from you! You’re not too late for Epic comments. I am writing up our meeting, but we are going to meet again, so I’m all ears going forward
I have to agree with the comment by PJGraham that copy and paste will only lead to poor habits and open nurses to legal problems. Letting nurses build personal templates may provide a hybrid option that nurses can use. Verifying elements of a pre-built note at least requires a quick review.
Another huge time-waster is all the useless extraneous information listed in chart reviews. For instance: I select ECG in chart review, select a specific test, and the page is literally full of useless data. Rather than a link to the actual test, the test should present itself and there can be links for all the other completely useless info. It’s as though the page is designed for the information management folks. IM are experts at where to find all the metadata and background info – nurses should not have to waste through that to get to info that can help make a care decision.
I love Epic. I worked with our Epic team to streamline the documentation for our nurses on my unit. It was fantastic. Copy/paste options were unfortunately disabled at one hospital, but not the other. It was an excellent feature. In regards to report, we could change and edit our report sheet page with the programers, but not on our own. We could decide on the type of format we preferred, like flow sheet. It’s amazing if unit supers work on behalf of the nurses to make it work for them! Reports and behind the scenes analytics were lacking, but improving. And in regards to dictation, doctors are able to do so using Dragon, sure nurses could for notes.
The implant record section of Intraop is badly in need of a scan function. To type out the long and painful record of every tiny screw’s size, type, expiration, etc is a waste of the nurses’ time when that info could be scanned from the manufacturer’s sterile packaging and then auto populate to the record .
I have nothing nice to say about Epic. It is set up in the most user unfriendly manner and needs a complete overhaul and rewrite. The endless useless check boxes, the I&O with IV fluids, the endless lists of completed meds, orders, procedures make it unwieldly. It has caused too numerous to count nurses to retire. I am one of them. It has turned critically thinking nurses into unthinking robots who check boxes all day long and no longer have time for what nurses love, taking care of patients. the best thing that could happen to Epic is that it disappears.
I truly understand your sentiment, but I don’t believe the problem is using an EMR. I think the origins of the most robust solutions were based in fulfilling requirements for a government mandate, and therein lies the problem. Rather than a goal of improving care through streamlining recorded data, the goal was to appease the standard gods.
If it would be possible to go back to the roots of the software and start from a premise of making caring for patients easier and more efficient while also improving record storage and retrieval, THAT would possible result in a solution that works FOR caregivers and patients.
As, Dr. Shepherd noted, the EHR (I avoid using EMR as calling it a medical record rather than a health record is problematic in my mind) was not built to support patient care, to facilitate communication among the team, nor to improve shared-decision making (health care providers AND patients together). If we look back at the Meaningful Use requirements, they do not reflect “meaningful use” in the way most nurses (or any health care provider) would describe this concept. And now we have moved on to “promoting interoperability” without ever achieving true meaningful use. I agree with others that we need to standardized documentation based on best practices so that a nurse or health care provider could as easily document in one system as they could in the next. We need to standardize documentation just as we standardized any other care practice. Research has shown that what nurses document is predictive of patient outcomes (deterioration, readmissions, etc) and the narrative note plays a role in this. Yet, when I was last discussing Epic with an ED nurse she said the narrative note had been removed at her institution. All documentation had been reduced to a check box/drop down. When trying to streamline or reduce documentation burden we must be careful what we eliminate. There is also research to support that documenting (the process of writing) supports clinical reasoning and other cognitive processes, if we delegate this work to Scribes or use only voice to text to overcome the burden of these new systems, we may also be “losing” rather than “winning”. Without nurses at the table and research to support what should stay and what should go, we may find ourselves woefully worse off. Some more of my thoughts in this piece: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30010-2/fulltext
Epic’s opening page could easily let us know who the patient is, and their unique characteristics. Ie. SBAR of this hospitalization which could autopopulate … There are many tabs that never get used and which clutter the view making it difficult to clearly anticipate patient plan for this day. We should have full tech capacity to: speak our assessments and have them transcribed; have equipment (pumps and monitors) automatically populate flowsheets; have reassessment alerts pop-up. Etc. There’s also the idiocy of big updates that take hours of time with downtime procedures that then require time consuming transcription. Why not have a downtime chart that converts to the real chart when downtime is over? (Much like ‘waiting to send until internet available ‘. Thank you for doing this work on behalf of our acute care health system work. Oh, and could the outpatient records be somewhere easy to find electronically?