Review Of Nurse Experiences With Electronic Health Records

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The article A Systematic Review of Nurses’ Experiences With Unintended Consequences When Using the Electronic Health Record by Sheila Gephart, Jane M. Carrington, and Brooke Finley, discusses the potential dangers of implementing a new EHR, or changing an existing one, from the perspective of the nurses who use the system daily.

This article can also be viewed in full text through the OHSU Ovid Medline database entry.


While EHR adoption has tripled in 2015 compared to 2009[1], there is research that demonstrates poor EHR implementation can result in unintended consequences, such as reduced patient safety, for nurses who directly care for patients. Little is known about experiences with unintended consequences from poor EHR implementation from the nursing perspective, and few studies have been conducted to investigate this. Through a review of 4 original studies, it was found that while nurses experience workflow changes, difficulty accessing important patient information, and must continually adapt to meet patients needs with imperfect EHR systems, they would prefer to stick with the paperless EHR system. To work around these issues, nurse administrators need to perform continual engagement with nurses throughout EHR design, and encourage them to speak up when changes made by the EHR would result in patient harm.


Studies of physician interactions with EHRs show that the following perceptions and reception of the system occur among the EHR users:

  1.	Added work
  2.	Persistence of paper system use
  3.	Threats to communication
  4.	Heightened emotions
  5.	Emergence of unpredicted errors
  6.	Alteration in power structure
  7.	Overdependence on technology

There were also found to be eight types of unintended consequences, barriers to efficient use of the EHR, with poor EHR implementation [2]:

  1.	More or new work
  2.	Alteration of workflow
  3.	Imposition of new demands on the system
  4.	Altered communication
  5.	Strong emotions
  6.	New kinds of health care errors
  7.	Shifting power across disciplines
  8.	Overdependence on technology

Of the eight unintended consequences, workflow changes and alterations to communication were the most concerning among clinicians. Wrong patient identification and juxtaposition errors were identified consequences as a result of poor EHR implementation, alongside the main eight consequences mentioned. Safety concerns, including "technovigilance" and delayed treatment, were identified through the studies of EHR implementation as well.

A review of 45 clinical scenarios revealed instances of misrepresentation or underrepresentation of data; these threaten the understanding of patient needs, as a result of inconsistencies, endangering the patient. Five types of misrepresentations were identified [3]:

  1.	EHR data too narrowly focused
  2.	EHR data too broadly focused
  3.	Display of data that miss critical information
  4.	Contradictory, redundant, or confusing data
  5.	Data distortions reflected both by user and sensors


Queries were run through CINAHL and PubMed, including full text entries, using the terms "barrier and work-around to electronic health record", "unintended consequences", and "nurs*" to include nursing, nurse, and similar terms. The search for relevant studies on nurse interactions with the EHR yielded 130 articles. Most were discarded for lack of relevance to the subject being searched for, and editorial and review papers were also discarded. After thinning out the search, five (5) articles were found to be relevant and were reviewed.


The five articles, published from 2009 to 2014, used in this review focused on the population of nurses that cared for patients directly at the bedside. The process of data collection included:

  1.	Asking clinical leaders to identify work-arounds and artifacts used
  2.	Conducting follow-up interviews with leaders
  3.	Observing 12 residential nurses (RNs) for 4 hours each day
  4.	Reviewing CPOE internal web site for information generated by clinicians

The discovery made from those articles was that, of the 40 work-arounds and 18 artifacts, 80% of work-arounds and 89% of artifacts were used to support care coordination to work around design errors in the CPOE.

An interview of 37 nurses revealed 5 categories in which they assess EHR systems:

  1.	usability
  2.	legibility
  3.	communication 
  4.	work-around 
  5.	collaboration

While the EHR was generally perceived by the interviewed nurses to increase legibility, the information was often irrelevant to the care of the patient, and they were concerned with the time required to generate documents[4].

In response to the EHR not properly linking nurse flowcharts to clinical events, nurses have been using the comment fields as a work-around to justify care for legal purposes, simplify use of the EHR, ensure patient safety, and improve communication within the team.

Recommendations made by the nurses to improve EHR flow for clinical care include:

  1.	Document clinical episodes without changing screens
  2.	Support for electronic notifications of abnormal measurements
  3.	Relating multiple sheets for presenting abnormal assessments, nursing interventions, and patient response

The studies reviewed found that complex EHR design made mistakes more likely when delivering care and resulted in missed information. Nurses also voiced feeling disempowered and excluded in the EHR decision process, and that their recommendations for improvement were not taken seriously. Despite this, nurses value the EHR over paper documentation.

Another interview with 12 randomly selected nurses was conducted for the Nurse Information System (NIS) module for EHRs. The interview revealed that while completeness of documentation, quick access to medication information, and bedside documentation abilities were satisfactory, there was dissatisfaction with the functionality of the charting and communication features. There were also notes about missing information, poor usability, and other factors that negatively affected patient safety. Recommendations were offered to nurse administrators to advocate training and implementation support for NISs.


The articles reviewed represented the state of science on nurses' experiences with unintended consequences while using EHRs at the time of publishing in 2015. Only one of the articles addressed a theoretical framework for their study, while the rest used qualitative components.

Implications for research

The study of nurse experiences is underdeveloped compared to other studies, thus the use of qualitative methods for the studies was the most effective approach. In an attempt to gain a better, more "real", sense of unintended consequences, nurse informatics employed more sophisticated and "hands on" methods. The theoretical and qualitative work that has been done will lead to further, more focused study of nurse experiences; Halbesleben et al have even developed a tool for making the measurement of barriers and work-arounds easier[5].

Implications for practice

The studies conducted in the articles suggest that there are a great deal of barriers and changes that nurse administrators need to conduct strategies for in order to keep patients safe and use of the EHR as free of errors as possible. Anticipating changes, ensuring nurses are involved in decision making, nurse administrators being involved during implementation, and training nurse "super users" were all recommended strategies that nurse administrators could implement for this purpose.


The purpose of the review was to obtain a summary of the state of science around nurse EHR experiences, and how nurses approach interacting with them to ensure patient care and safety. The studies found that nurses require a great deal of vigilance and planning when interacting with the EHR in order to accomplish safe patient care, and will need to continue planning as EHR technology grows.


  1. Gephart S, Carrington JM, Finley B. A Systematic Review of Nurses' Experiences With Unintended Consequences When Using the Electronic Health Record. Ovid Med. 2015 Oct-Dec. 39(4):345-56.
  2. Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2007;14(4):415-423.
  3. Smith SW, Koppel R. Healthcare information technology’s relativity problems: a typology of how patients’ physical reality, clinicians’ mental models, and healthcare information technology differ. J Am Med Inform Assoc. 2014;21(1):117-131. doi:10.1136/amiajnl-2012-001419.
  4. Carrington JM, Effken JA. Strengths and limitations of the electronic health record for documenting clinical events. Comput Inform Nurs. 2011;29(6):360-367. doi:10.1097/NCN.0b013e3181fc4139.
  5. Halbesleben JR, Rathert C, Bennett SF. Measuring nursing workarounds: tests of the reliability and validity of a tool. JNursAdm. 2013;43(1):50-55. oi:10.1097/NNA.0b013e31827860ff.

Submitted by Nathan Gerstmann