Analyzing Free-Text EHR Orders to Support Clinical Workflow Optimization

Understanding the scope and drivers of the use of nursing-related free-text EHR orders can help guide clinical workflow optimization, according to a study published in JAMIA.

Researchers led a retrospective analysis of free-text EHR-based communication orders sent to or by nurses providing inpatient care at an academic health system.

Order content spanned 20 different care domains, with providers indicating nursing-related orders for physical regulation, fluid volume, nutrition, safety, and medication most frequently.

One-third of the orders included two or more requests, and providers often paired care domains if an order had two requests.

“Providers may have an unmet need to communicate requests as sets of requests related in time or relevance, and this functionality is poorly supported using standard domain-specific order templates,” the study authors wrote.

While a governance process predefined some of the observed patterns for free-text orders, providers created other orders “on the fly.”

Those orders bypass existing EHR functionality designed to aggregate data for CDS and clinical documentation.

“Some patterns reflect provider behaviors that may require training to use existing tools or usability assessment to understand why standardized order templates are not being used,” the study authors noted.

Other patterns reflect EHR problems that force providers to use “workarounds.”

For instance, one pattern asks a nurse to discontinue an intervention for which there is no current order. The researchers explained that this workaround exists because the EHR order entry system does not implement documentation for placing lines and drains in some settings. Providers use “preference cards” in the operating room to document requests.

“Thus, the initiating orders for lines and drains are not available to document discontinuation when patients are moved to an inpatient unit,” the authors said.

Providers could avoid this workaround if the EHR automatically generated orders based on requests defined in “preference cards” that end-users could discontinue.

The lack of interoperability between workflows causes a “cascading effect of workarounds,” the authors noted.

“Currently, the inpatient provider may waste effort searching for non-existent orders and ultimately write a free-text order,” the researchers said. “The nurse must then search for the order in a miscellaneous list, potentially requiring to resolve duplicates, all of which disrupts the nursing workflow.”

The authors gave several suggestions for improving the use of nursing free-text EHR orders.

First, they suggested that organizations develop a policy that describes situations when it is acceptable for providers to use nursing-related communication orders. The authors emphasized that the organization should design the policy with input from key stakeholders, like providers, nurses, and informatics specialists.  

Additionally, they called on healthcare organizations to address specific system-related factors that encourage providers to use nursing-related communication orders (NCOs).

“For example, explore whether preference cards can automatically generate orders and whether predefined orders in order sets can be developed using standard templates,” they wrote.

Lastly, the researchers suggested that organizations monitor NCO usage across settings over time, focusing on orders that providers create “on the fly.” Analyzing these patterns can help guide efforts to reduce nurse burnout, they said.