Three’s a crowd, so what can nurses do when they find a computer alongside their patients in the exam room? Are communication and patient care doomed to suffer when electronic health records (EHRs) replace paper charts? Not necessarily.

“For our inpatient nurses, using electronic medical records is a very new concept,” says Mary Jo Williams, RN, regional director of Kaiser Permanente Medical Group (Northern California) Nursing and Clinical Practice. Kaiser Permanente (KP), the nation’s largest nonprofit healthcare system, is in the midst of a massive, multiyear initiative to establish EHRs for all of its 8.5 million members.

So far, at least 70 percent of KP members have at least some of their records on the system; all members’ records will be fully on board by 2008. EHRs are winding their way through every part of the KP health system -- all 32 hospitals and medical centers as well as more than 430 medical offices. To help orient nurses in the use of EHRs, KP is providing both extensive classroom instruction and on-the-job practice.

Practice Makes Perfect

With any new system, it’s important to become as proficient as possible before going live with patients. For example, users of EHRs that require typing could bone up on weak keyboarding skills. Since most EHRs require users to complete templates, it’s best to familiarize yourself with the format beforehand so you can focus on the patient, not the screen.

“But the biggest challenge for nurses is often not learning the new computer application, but rather its integration into their workflow,” says Judy Murphy, RN, a fellow in both the American College of Medical Informatics and the Healthcare Information and Management Systems Society. At Milwaukee-based Aurora Health Care, Murphy led the EHR implementation, which involved bringing computers to patient rooms and nursing stations in all 14 Aurora hospitals.

Since many Aurora facilities rely on portable computers, nurses now wheel a computer around on a cart. They build their assignment sheet differently and have learned to chart differently, but their job of providing patient care remains unchanged, Murphy says.

Build Communication

How can nurses maintain patient-centered care while using EHRs? Follow these tips:

• Begin by Establishing Rapport with the Patient: “Instead of walking right to the computer when entering an exam room, greet the patient and listen to their concerns,” suggests Sara Kooienga, FNP, assistant professor in the advanced nursing program at Oregon Health & Science University. Kooienga, who researched exam room communication and EHRs when she was with the Providence Health System, suggests it may help to review notes from the previous visit before you enter the room.
• Maintain Eye Contact: Try never to turn your back on a patient. That’s easier when the computer is on a cart, on a properly angled counter or attached to an arm. Maintaining eye contact is especially important when discussing sensitive issues.
• Get the Patient’s Approval: Before you start entering data, explain what you’re doing and ask for the patient’s permission, just as you would do before touching a patient for a physical exam, suggests Williams. Ask, “Do you mind if I enter some of this data while I’m talking with you?”
• Explain Yourself: Don’t sit silently staring at the monitor, scrolling through screens or endlessly clicking. Tell your patients what you’re doing while you’re doing it, suggests Kooienga. Try to keep talking as you work.
• Involve the Patient: Chart in the exam room if you can involve the patient in some way, says Williams. Otherwise, you might be better off jotting down notes while you’re with the patient and entering the data afterward.
• Tap the Teaching Potential: EHRs can display patient data in a way that has great visual impact, such as charts and graphs that show trends in blood pressure for heart patients or insulin levels for diabetics.

By following these tips, nurses can turn an exam room computer from an intruder into an ally.