Game-changing EHR improvements at Intermountain, UCLA, and 6 other systems

As the clinician burnout crisis continues, it's important that hospitals are doing all they can to optimize EHR workflows. Here, IT executives from eight health systems across the country share the EHR workflow improvements that have saved their clinicians the most time.

Editor's note: Responses were lightly edited for clarity and style.

Ryan Smith. CIO at Intermountain Healthcare (Salt Lake City): Working in collaboration with our front-line nurses, we have been able to significantly reduce the documentation burden for physical assessment documentation in medical-surgical and critical care units. Our IT teams worked together with nursing teams to review and define essential clinical documentation needs. This collaborative work resulted in redesigning the nursing documentation tool and workflow in our EHR.

Results of the redesign for the Adult ICU Systems Assessment included an annual decrease of 11,101 hours of nursing documentation time and 27.4 million fewer clicks in the system. Similarly, improvements in the Adult Med Surg Systems Assessment included a reduction of 38,075 hours of nursing documentation time and 78.6 million fewer clicks. Finally, our Pediatric Physical Assessment nursing documentation saw a reduction of 1,644 hours and 3.1 million fewer clicks in the system as a result of the redesign work.

Rich Rogers. CIO at Prisma Health (Greenville, N.C.): A few years back, we saw the need to redesign how we screened for vaccination needs in the acute-care setting. There was an update to pneumonia vaccines regarding who and when they qualified, and when flu vaccines are required to be screened/administered in certain environments. We had internal organizational goals to vaccinate as many patients as we could. Historically, it was a nurse-driven screening process, but there were a number of issues in the process. 

We created a workflow utilizing Epic and health maintenance. If the patient had not received the appropriate vaccines (focusing on influenza and pneumococcal), the age and condition of the patient was considered, and Epic would provide the pre-selected order that is appropriate for the patient in any admission order set used. It is then scheduled on the medication administration record, and the nurse does a final screening to ensure it was not received this year and there were no allergies. It reduced our nursing time drastically since they were no longer responsible for documentation and ordering, only the administration. 

We worked closely with our pharmacy team on a process to return "refused" vaccines to minimize wastage. We also embedded the vaccine information sheet into the workflow so the nurse was not required to search for it. If a patient has already received the vaccine, and it is documented in Epic, then the order is never displayed. We also were the first in the state to have a bidirectional interface with our state agency to receive vaccine data back into our EHR. This allowed the medical record to most accurately reflect the patient's vaccine status.

Ellen Pollack, MSN, RN. Interim CIO and Chief Nursing Informatics Officer of UCLA Health (Los Angeles): In response to COVID-19's increase in nurse workload, UCLA Health created and implemented special protocols to reduce medical record documentation burden and increase the time our nurses spend at the bedside. We made significant reductions in the amount of required documentation, keeping only those elements that were essential. Key considerations included patient safety, regulatory requirements and interprofessional communication within the medical record. After conducting a pilot, we surveyed the nurses to get their feedback and made adjustments based on input. The special "disaster" protocols were then further deployed to all medical-surgical units, ICUs and the emergency department.

We saw on average an 11 percent reduction in documentation time. No safety events were identified due to the decreased documentation. A survey of our nurses indicated that 88 percent reported they were able to spend more time with their patients. According to Ida Anderson, our director of nursing for adult critical care, clinical nurses expressed tremendous relief about the change. The change provided a tremendous relief. Disaster protocols often made the difference between working 12 hours per day compared to 13.5 hours. Nurses can focus directly on bedside care during these challenging times while knowing that the most important information is being communicated within the medical record. Nursing leadership monitors the use of this protocol carefully, and, when the workloads stabilize, they make the decision to return to standard nursing documentation.

Michael Pfeffer, MD. CIO at Stanford Health Care (Palo Alto, Calif.): At Stanford Health Care, we are constantly optimizing the EHR to improve clinician efficiency through a collaborative effort with IT, informatics, clinicians and operational leads. One impactful improvement was the integration of our inpatient infusion pumps with our EHR. This project was designed to increase clinician efficiency and patient safety by automatically sending infusion medication orders from the EHR to the pump, and subsequently receiving infusion data from the pump to file back into the EHR. This removed the need for manual programming of the infusion pump and clinician documentation of the individual infusion medication rate/volume information in the EHR. 

The largest impact to clinician efficiency can be seen in the ICU, where patients typically have several infusion medications running simultaneously that need to be changed daily. It also increases patient safety by including the scanning of the pump as part of our closed-loop, barcoded medication administration process. Errors associated with medications are the most frequent cause of adverse medical events according to the Agency for Healthcare Research and Quality, and this project not only improved clinical efficiency but also patient safety.

Eric Neil. CIO at UW Medicine (Seattle): With increasing demands on our providers from regulatory, quality, consumer and revenue sources, combined with the recent pandemic, the clear path forward for healthcare IT is to provide solutions which maximize the benefits of team-based care. One of the primary functions of an EHR is to bring data together from those care team members into a clinically designed, consolidated format to facilitate both data review and documentation. 

On the inpatient side, we designed review summaries that clinically organize data around a patient's conditions, whether it is for a chronic disease like diabetes with our glucose summary reports, or an acute condition like our fever/infection reports. From the documentation side, we have constructed standardized templates to pull in and organize all relevant information for that specialty, for that patient. Both have been shown to save clinicians time and improve outcomes. Standardized order sets and clinical pathways support safe, effective and efficient care. Widespread use of electronic medication prescriptions improves patient safety and clinician efficiency, with one physician recently commenting, "discharging patients with opiate prescriptions is much faster now that I don't have to hunt down a printer that hasn't been depleted of tamper-proof paper."

On the outpatient side, promoting tools that give a longer temporal overview of a patient like lifetime and care integration with health information exchange tools such as Care Everywhere have been crucial to reviewing data. In addition, we are implementing new tools besides templates to aid with documentation and ordering. These include voice functionality such as Dragon Medical One and Hey Epic. Finally, a significant amount of time is spent by clinicians just trying to communicate with each other. The wide adoption of secure chat, our new intra-EHR messaging tool has proven to increase efficiency, and we are already seeing over 35,000 messages a day across the system.  

Brian Clay, MD. Chief Medical Information Officer at UC San Diego Health: I would say the most impactful EHR workflow improvement over the last five years or so would be continued implementation of EHR functionality within mobile applications. By extending capabilities beyond the desktop, clinicians are able to address patient care issues in multiple environments and on the go. Our outpatient physicians have the ability to electronically prescribe medications and write notes using the mobile application version of our EHR. On the inpatient side, writing quick orders on hospitalized patients can be done with a few taps on a smartphone. 

The advent of mobile functionality has allowed us to implement and advance EHR-integrated secure messaging, which allows much quicker back-and-forth conversation for brief questions than a page or a phone call. Finally, mobile capabilities allowed us to quickly ramp up full telehealth video visit capabilities at the beginning of the COVID-19 pandemic and remains a key part of outpatient clinical management now almost two years later.

Michael McTigue. Vice President of IT at Cooperman Barnabas Medical Center (Livingston, N.J.): At Cooperman Barnabas Medical Center, we have the only certified burn unit in New Jersey. Taking pictures of burn sounds and getting them into the online chart is critical to the burn surgeons. They were doing this by taking the picture with their phone, copying and pasting into the chart. Working with Cerner, we installed a module that brings up the patient list on their phone, allows them to take the picture and transmit directly into the EHR via wireless. It has reduced time for the surgeons and enhanced their workflow significantly.

Carl Smith. CIO at King's Daughters Medical Center (Brookhaven, Miss.): Over the past two years, we have invested in a digital transformation strategy in order to optimize efficiencies for the clinicians. With patient volume surges and staffing shortages, we had to find creative and innovative solutions that would help our staff reduce stress and be more productive. The solutions found were ways to optimize our current Meditech Expanse Patient Care EHR to a more mobile, web-based platform that's easier to manage and navigate. This proved to reduce task times and improve user satisfaction.

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