Words of Wisdom: What’s Your Advice For EMR Newbies?

When Chad Johnson asked me to become a part of the blogging team here at HL7Standards I was a bit hesitant. In fact, I think I let his email sit in my inbox for at least a week (or two or three) before responding. It’s likely he had to send me a second email before I actually responded.

I remember thinking, “Why is he asking me this? Doesn’t he know I don’t know anything about health IT and EMR?” When we finally connected I did my due diligence and reminded, aka warned, him that I had been out of the clinical setting for eight years, unless you counted the advice I gave coworkers who wandered up to my cube and asked, “What do you think this is?” while pointing at a rash on their arm, leg or thumb. My standard answer is always,”Ooooh, look at that! You might want to call your physician. Please don’t touch anything on my desk.”  And I didn’t use any EMR or health IT for that.

Chad thought I was up for the challenge. Still, I tried to dissuade him. “Computers weren’t invented yet when I was working the unit,” I told him. We both knew that was a lie.

When I worked as a nurse, we used CPOE (computerized physician order entry). We were piloting electronic medication administration record and we had a Pyxis machine that had to be stocked with chocolate so the nurses would actually want to figure out how to work the thing. But everything else was done on paper. Sometimes it was even carbon copy paper. So I would say that I have not worked in a fully functioning EMR system. But, somehow, Chad managed to convince me I could handle it, so I said “yes.”

peanuts-bloggingOver the past year, I’ve enjoyed blogging because I learned a lot about EMR and health IT and the people who work in the industry. But sometimes I still feel like I’m not totally “legit” because I’ve never had an experience of being immersed in a fully working, bells-and-whistles-type EHR system. But in the next few weeks that is going to change.

I’ve resigned my position as a cube dweller and will be heading back to clinical work as an admissions nurse at a local hospice. I’m excited about this position for many reasons. I’ve always felt that hospice nurses were special—a different breed from the rest of us. And now I get a chance to see if I can evolve to become like these nurses I’ve so admired. I’ll also get a chance to take part in something that was just going mainstream when I left my last clinical position nine years ago, EMR and health IT. I’ll finally feel “legit” when I write about healthcare technology!

Though depending on who I ask, EMRs aren’t all they’re cracked up to be. I remember when I was a new grad I boldly asked one of the more seasoned nurses why we didn’t use an EMR. She said they piloted it on one unit once and they all hated it so it just went away. When I interviewed for this new position, I asked what the most difficult part of the position would be for a new person. The two answers I expected were: 1) being surrounded by death and dying all the time, or 2) having to relearn all my clinical skills. I was somewhat shocked when they told me the biggest challenge would be learning the EMR system.

How hard will this be, I thought? After all, my generation was one of the first to use computers at an early age. It can’t really be much worse than some of the programs we use in the publishing world, and I’ve managed to learn those. It can’t be that bad.

Yet, some nurses I know stress that EMR has become the worst thing about nursing. They feel it disconnects them from their patients and that it is cumbersome and not user friendly. Therefore, it makes their job more difficult.

I heard similar complaints from my mother, who is a nurse, last week while we were out to dinner. Ironically, one of the girls at the table behind us worked in a medical office. I know this because I was eavesdropping. She was complaining to a friend that it was a difficult place to work because they had no EMR system. Which is the right perception? In 10 years what will I be saying about EMRs?

I’d like to invite every reader of this blog to  follow me down the EMR road and to offer advice on my journey. I really want to adapt to and succeed using EMR, but I’m not quite sure where to start. Do any of you experts (yes, this is a good opportunity for consultants to speak up below in the comments) have advice for someone like me? What’s the best ways to use EMR to its fullest? Will I feel a certain way during the first week? What should I be prepared for?  What types of questions should I ask about the technology?

I have exactly one week until I start the new job, so any and all advice is appreciated. You’ll also see frequent posts from me detailing my learning process and finding experts to help sort out things.

All this is exciting and new to me and I hope you’ll be able catch the spark and become passionate about helping others learn how to use EMRs.

I’m more than happy to get all the advice you can give, so please comment early and comment often!


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Jennifer Thew, RN, MSJ

Jennifer Thew, RN, MSJ, is a registered nurse and journalist who has covered healthcare issues and how they relate to the nursing profession. She began her nursing career as a neuroscience nurse at Rush University Medical Center in Chicago and then transitioned to journalism after receiving a degree from Roosevelt University in Chicago. She has edited and written numerous articles on a wide range of nursing and healthcare topics like Accountable Care Organizations, evidence-based practice and telehealth.

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  • JayM_HealthIT

    OK I’ll bite!
    Hi Jennifer. Obviously , it will be difficult to speak in specifics without knowing what EMR you are using. I do support for GE centricity so my advice might user some terms that aren’t 100% correct in your environment.. but I bet anything I describe has a close similacrum.

    Which brings me to my 1st point. Anytime you learn something new… learn the language first. when working with co-workers, identify the ones that endevor to use the right words to describe what they are doing, and learn to talk like them. If you get the oppertunity to interact with the vendor or similar support persons… listen to how they talk about the EMR. Shaping your understanding of something with language I believe to be vitally important.

    So now I am going to start using some of that language.

    In EMR, nothing gets done without a Document (aka an ‘update’)

    You’ll never add a diagnosis, or a prescription or record an allergy for a patient without one of these. A document is typically going to consist of the ‘chart note’ which is the providers narrative/human readable note. But additionally, its going to have one or many of these things on the back-end to track discreet values.

    in my world these are called ‘clinical list changes’ and ‘observation terms’

    Clinical list changes include things like a patients Allergies/Meds/Problems and Directives. They added/changed/removed in an update ,and a chain of historical events is kept for each item added/changed or removed.

    (a very simplified example)

    1. 1/1/2000 – created RX for Lisinopril 10mg tabs

    2. 2/2/2001 – refill of Lisinopril 10mg tabs

    3. 3/3/2002 – changed RX from Lisinopril 10mg tabs to Lisinopril 15mg tabs

    4. 4/4/2003 – stopped med RX Lisinopril 15 mg tabs

    Observation terms are essentially buckets that hold other pieces of data. Lab results, Vitals, EDC, LMP, etc.. these are all examples of pieces of data that you need to track in a way that you can sort and filter them with a computer, and so these can be captured as well in a Document/Update. Observation terms can likely be entered into the system in a number of different ways… Try to develop an understanding of all the different ways these values can be entered.. (via a form, a flowsheet, quicktext/shortcut) when you do , you’ll understand that that no matter HOW they got in there, the remain the same basic thing. Many Many gears in the EMR turn on Observation terms (or whatever your emr calls them)

    Finally there is the concept of Signing. Signing is the act of committing an update to the patients chart. When a physician. (or a user who has the ‘rights’ to sign) signs a document they are essentially saying that everything in that document is true and accurate, and therefore a signed document is done. it cannot be changed. It is more or less a permanent part of the patients chart.
    Good luck!!

  • Jennifer

    Thanks Jay! This does seem to make sense to me. When I left clinical nursing in 2004 to go into journalism we had CPOE and were “piloting” computerized MAR. We still charted in DAR format on paper charts. And if we need to find the CPOE they were in a hard copy medical record….not an EMR. The Pyxis machine was brand new. Everyone seemed to like it thought because pharmacy filled it with candy….I’ve never seen nurses learn something so quickly! So I know it’s going to be at a much higher level 9 years later. Fortunately for me, I’ve been using an extremely user unfriendly document management system for the past five years. I honestly don’t think anything can be worse that that….maybe just as bad, but definitely not worse.

  • Jennifer

    Also, what you think nurses find most intimidating about what you’ve described?

  • Jibaro009

    EMRs are difficult and challenging to work with because their user interfaces are poorly designed. We are in the process of buying a new one and they all look the same (not good). Once you figure out your way through the software you’ll be felling right at home.

  • iaconojoei

    Having trained medical records for the past ten years I would say that the biggest challenge for clinical users of a new emr system is the disconnect between workflow and training. Communication comes in second as many times senior leaders know more about the partnership with the software vendor and do not share a larger plan with clinical end users. Training is mostly focused from the vendor point of view (ie. cookie cutter driving instructions ‘ click here, click here’) and little effort is made to integrate the workflow of a specific unit, process or procedure. It is assumed that RN’s and MD’s know the workflow and that trainers are not there to teach ‘policy and procedure.’ However, sites where I have had the opportunity to integrate both workflow and computer training have garnered the best comments from end users. The reasoning is simple: vendors charge extra for workflow and communication programs and emr systems are sold with ‘support’ and ‘training’ which the hospital executives assumes will be communicated from their end users point of view. Consultants who are called in to build the system are separate from the consultants who train and training materials are often recycled from one site to another, again with no focus on workflow. In my opinion it takes approximately six weeks for the new system to become invisible to end users and for life to return normal on the unit. Changes occurring over time because of new regulations or meaningful use requirements need proper communication/training and again, it should not be assumed that clinicians are just there to follow instructions. They are highly skilled and deeply caring about patient safety and thus it is our job as trainers to give them as deep a knowledge (deep dive) into workflow and training as one. I believe that this will start to happen more and more over time and that good institutions are already doing this.