A meeting with Epic

Our January 2022 discussion with the leading charting software maker focused on ways to improve nursing care

Truth About Nursing director Sandy Summers and colleagues recently met with representatives of Epic. They discussed how charting software might be improved to reduce the burden on nurses and allow them to give more and better patient care.

January 14, 2022 — Today Truth About Nursing director Sandy Summers had a virtual meeting with representatives of Epic, the leading creator of the charting software U.S. nurses use in clinical practice. Specifically, we met with Emily Barry, Epic’s vice president of nursing informatics, and Joe Zillmer, a nursing well-being expert who works directly with nurses who use Epic. Also on the call was Ellen Makar, RN, DNP, the system VP of Hartford HealthCare. Dr. Makar had recently reached out to us to discuss our ideas to reduce charting burdens to improve the time nurses have for patient care. So we invited Dr. Makar to join us on the call, along with Hartford HealthCare’s Chief Nursing Information Officer, Sue Marino.

On the call, we discussed with Epic our concerns that nurses seem to spend at least as much time on Epic as they spend with patients–in effect turning upside down what good care should be. In this regard, we appreciate Jenna Thate’s (RN, PhD) correspondence linking us to her work on electronic charting, including research finding that nurses actually spend twice as much time on electronic charting as they do with the patient, which we shared in the meeting. Below we discuss these concerns as well as some proposed solutions.

Our Main Concern: Missed Nursing Care

Based on our observations, over the past two decades nurses have come to spend so much time charting that clinical nursing itself has changed. No longer are nurses spending the majority of their time at the side of the patient. Now we are primarily glued to our computers. Of course, nursing is a knowledge profession, and we must convey a significant amount of clinical information, based on our assessments and interventions, to play our key role in the modern health care system. But the clerical work it takes to convey this information is onerous and takes away from time nurses actually need to be able to do them.

We have come to a place where we can either chart these interventions or do them, but not both. In the current practice environment, where nurses are often understaffed to start with, the charting burden can be untenable. As a result, so much care has been omitted, on such a regular basis, that it seems some nurses no longer even know that they should be doing a great deal of patient care. Nursing scholar Beatrice Kalisch has clearly demonstrated the extent of this problem in her research on missed nursing care.

Here is a list of commonly missed types of nursing care:

• Assessments, decreased frequency and thoroughness;
• Turning patients, preventing and monitoring pressure sores;
• Oral care;
• Bathing;
• Skin care;
• Incentive spirometry;
• Mobility care–exercise, walking, range of motion, taking the patient to the bathroom instead of giving them the bedpan–in accord with what the patient will tolerate;
• Changing dressings on IVs and central lines so they actually are “clean, dry and intact,” just as the charting says they are;
• Shaving patients, whether their faces or removing body hair so their dressings stick better and we don’t rip their hair out when we remove dressings and ECG leads;
• Advocating for patients, making sure the care we are providing is in their best interest;
• Engaging with patients and families, asking them about their lives, careers, and interests to provide a human connection and decrease their isolation;
• Tracking down providers to share information and adjust medications and care plans;
• Educating the patient and family, providing information about how to manage and improve health;
• Updating the family about patient events so that they remain informed and included as part of the care team;
• Advocating for better hospital systems, including dietary service that promotes health instead of decreasing it, and supplements like vitamin D, the meditative and peaceful Care Channel, edutainment such as the movie Forks Over Knives, and basic music choices that research shows improves patient health;
• Did we miss some? Please email us your additions at epic@truthaboutnursing.org.

Key Topics Addressed on the Call with Epic

Our time on the Epic call was limited in view of all the issues above, so to start we focused on a few things, each of which is discussed in more detail below:

• An electronic report sheet so that nurses can use the data they enter at report time;
• Voice recognition to reduce the charting burden on nurses;
• Easier ways for nurses to communicate with providers, to enable better patient advocacy and the recognition of nursing autonomy in the clinical setting;
• More accurate and respectful software terminology.

Nurse Report to improve data sharing / storytelling

We discussed how the entry and storage of data in spreadsheet cells can isolate key care information in thousands of tiny boxes. That may leave no good way to use it to tell the story of the patient, as nurses do when they give report every shift. Ms. Barry was quite interested in this issue, and we explored existing Epic pages that might provide a jumping off point to build a nurse report sheet. We discussed retaining snapshots of nurse reports at each change of shift and finding a way to show the trajectory of changes in patient symptoms over time, so clinicians can see where patients have been and where they are headed.

Voice Recognition to streamline charting

We were pleased to learn in the call that Epic is beginning to launch some voice recognition features with its Rover mobile phone app. As this is in early stages and new technology can take time to perfect and distribute, we think it is still important in the meantime to hire scribes for nurses. Doing so would greatly ease the burden of charting on nurses, and allow them to do the patient care that has been set aside for the sake of charting. Learn more by clicking the button below.

Protecting nursing autonomy

Improved interaction with Providers

Despite time constraints, we were able to briefly discuss improvements in nurse-provider communication, which is critical for nurses to advocate for patients. Epic does have a chat function that is employed at some workplaces, but ideally that kind of interactive feature would be improved, and become standard practice everywhere. When nurses struggle to find out which provider to approach for patient needs, to track down the right phone number or pager, or to avoid contacting providers at the wrong time of day or night, it takes so long and inhibits patient advocacy and communication. In effect, nursing’s thoughts, plans and ideas for improved health may be silenced and omitted. And over time, nurses may begin to forget that it is their job to weigh in on how to improve care. Then nursing practice changes, so that nurses and providers alike think nurses exist mainly to “follow orders” and do whatever providers prescribe without question. This is damaging to the nursing profession, but it is especially threatening to patients, who need nurses to be full care partners who can provide a clinical backstop and bring their unique perspective to bear on care plans and decisions.

Changing “orders” to “prescriptions” or “scripts”

Patients rely on nurses to function with great autonomy and question every planned medication, test, procedure or activity with skepticism–examining proposals for a change in plan to make sure they are in the patient’s best interest. Nurses no more “follow orders” than do patients. Nor should either one of them.

The word “orders” sends the message that providers are in charge and whatever they say must necessarily be followed. In reality, the patient is in charge of their care and any plan of care or change to it should be signed off by them. But to the extent patients are awake and able to affirm their plan of care, they rarely know or understand that they are in charge of their care. Worse yet, physicians and some nurses may not know it either.

When patients are too sick affirm their care plan, or the plan change is not significant enough to bring to the family’s attention for their agreement, nurses must be the ones who decide whether the change in care is in the patient’s best interest or if they should bring it to the family for their attention. Nurses must always advocate for the patient, no matter what.

A language change to remove the word “orders” from the electronic chart and the way we communicate could help nurses practice with greater autonomy and protect patients. Ideally, the word “orders” would be replaced with “prescriptions” (“scripts”) or “care plans” to help provide clarity to patients, nurses and providers that patients are in charge of their care, not providers.

If nurses believe that a care plan is not in a patient’s best interest, they must act as a patient advocate in discussing the plan with the colleague who made the plan, and negotiating for a better plan of care. Ultimately, in a future world, the patient or their family should affirm whether they would like to go along with the proposed plan of care or decline it.

“Acknowledge order”

Nurses commonly question physician and advanced practice nurse care plans, and in general the health care workers reach an understanding as to what appears to be best for the patient.

Nurses do not just “acknowledge” prescriptions. They must agree with the plan or reject it and communicate that with the provider and advocate for a better plan of care. To protect nursing autonomy and patient well-being, nurses need a chat box to say, in effect, “This plan may have problem ABC because the patient has LMN symptoms/problem. What do you think of alternative XYZ instead?” That would enable the nurse to provide critical feedback, as well as to help both nurses and providers understand that nurses are partners who do not necessarily do whatever providers prescribe, but who can and should participate in health care decisions.

On those rare occasions when there is continued serious disagreement about a plan, nurses would ideally decline to implement the plans and consult the ethics committee. There should be an easy and electronic way for nurses to also contact the ethics committee.

Respectful Language

We were also able to briefly discuss some software terminology that may tend to undermine perceptions of nursing autonomy or skill, with negative effects on care. We noted that the use of the term “the brain” might suggest to some that nurses’ brains actually reside in the software, so something like “planner” or “organizer” might be better. We did not have time to discuss other potential language improvements, but below is our current list:

• “the brain” to “planner” or “organizer”
• “task list” to “checklist”

Interactive feature with patients

Suggestion from Carole Eldridge, DNP, RN, CNE, NEA-BC:

I would love to see a Patient Pain Med Request app as part of EPIC. Patients could request pain meds on their phone, thereby recording their request, which their nurse would receive directly. It would be recorded and accountability would be greater. While this would help patients, it would also help the nurses be more efficient and effective in pain management. The app could prompt the patient to record the effectiveness of the pain med at a set time period after administration.

Future work with Epic

We are planning to meet with Epic again soon to continue our discussions. Stay tuned and please send us your suggestions for discussion points and improvements to epic@truthaboutnursing.org. Thank you!