Electronic Medical Records: How Can We Bridge the Gap Between Clinicians & Technology?

When I first became a nurse, we didn’t have electronic medical records, and we wrote everything longhand.

At the end of every shift, we stacked up our charts and wrote a note about how the shift went, issues the patient had, attempted to read and transcribe orders, and manually counted and documented all the narcotics… you get where I am going.  

And even though now I am not sure how we did it, I was still hesitant to give it up and transition to utilizing the electronic medical records that were emerging in our practice.

I didn’t want to give up my brain. I didn’t think I could manage my workload and all that ‘computer stuff.’

I didn’t think it would be any faster! 

Nonetheless, I adapted, learned, and some days muddled through, knowing paper charting was soon to be outdated and electronic medical records would be the new normal. 

When an opportunity presented itself to work behind the scenes, I took the plunge. It is incredible all the places we can go with our nursing career!

However, transitioning to a behind-the-scenes role did have its struggles. While my peers were trying their best to get a handle on all the changes coming at them, my dive into technology alongside the Information Technology (IT) team was near mutiny and a great deal of frustration at first.  

Like any dutiful nurse, you want to get to the source of the problem.

I began collecting data, and through informal conversations within my practice, I found that there is a huge gap between what goes on behind the scenes with electronic medical records from an IT perspective, and what is occurring at the patient’s bedside from a clinician’s standpoint.

The most prevalent factor in this issue was both teams operating on different jargon-based languages! Without a common language, neither side could understand the other’s concerns, constraints, and solutions toward progress and positive patient outcomes. 

How can clinicians and the IT team collaborate to improve outcomes in your practice?

– Be prepared to describe the expected workflow

Who are all the players involved in this patient care activity? What do each of them do? What is the evidence that exists showing this is a problem?

– Was something implemented that is not going well?

Let them know. Do not adopt a workaround because if they do not hear from you, they assume it is going well. Don’t be afraid to admit if an idea did not work the way it was intended to — we are a team, and this is how we learn! 

– Have examples!

If something is not working, having a nurse or clinician example of whom it is not working for, or a specific patient that it is not working for helps the IT team troubleshoot and solve the problem. Bring it to their attention; they want to know! They want to fix it. Not having an example would be like another nurse telling you ‘Someone needs pain medication’ as they leave for lunch.  

– Have an idea that might make something easier?

Write it down! Share it. They want to know how to make the system work better for you. Be open to conversation about how the electronic medical records systems work, what its limitations are, how it might be able to help you, etc. They are the technology experts!  

– Don’t understand the terminology they are using?

Ask questions! They might not understand you either, especially with the specific terminology within the electronic medical records. Being brave enough to ask them to clarify questions might help them relax, too, and do the same in return! 

– Be appreciative!

Being behind the scenes is very stressful. They want your job to be easier. They put patient safety first too. Many of your IT team were once on the floor, and they take great pride in being able to help make your day run smoother. They aren’t trying to make it harder! 

Having electronic medical records comes with many advantages — patient care is streamlined, results are available faster, data is quickly available to improve outcomes, and warnings can be implemented to improve safety and decrease sentinel events.

To leverage it to its fullest, there must be a collaboration between the clinicians using it and the IT team charged with maintaining and optimizing it.  Developing a common language and an understanding of one another’s workflows and pain points can go a long way toward fostering positive relationships, increasing collaboration, and decreasing disengagement on both ends.

Bridging the gap between clinicians and IT can help ease frustration and provide a forum for continued innovative solutions and excellent patient care! 

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