Epic EHR Optimization Enhances Nursing Clinical Documentation Workflows

A multi-year Epic EHR optimization project cut clinical documentation time for acute care nurses, resulting in enhanced end-user satisfaction.

Complaints from acute care nurses about overly time-consuming clinical documentation tools prompted the EHR optimization effort at UCHealth, based in Aurora, Colorado.

Bonnie Adrian, research nurse scientist for the clinical informatics team at UCHealth, said that reports from the organization’s Epic EHR revealed that acute care nurses were spending more than 30 percent of each 12-hour shift working in the EHR.

With the support of UCHealth’s Chief Nursing Officer Council, Adrian created a task force to comprehensively review the documentation tools acute care nurses used most frequently.

The team of nurses, nurse managers, and nurse educators evaluated nursing documentation requirements. The task force only kept information in the documentation tools that met one or more of the following criteria:

• It is needed to provide patient care.
• The nurse is the best or only person to document it.
• Flowsheet entry is the best or only way to enter the information.
• It is required by reporting mandate or regulatory compliance.
• It populates the patient header or a critical report.
• It triggers actions needed for specific workflows, such as a consult.
• It is necessary for billing or reimbursement.
• It is required to document that a patient refused care.

By removing rows and values that did not meet any of these criteria, the task force eliminated 25 to 50 percent of the options nurses saw in their flowsheets.

The team then worked with clinical informaticists and IT analysts to improve documentation workflows by redesigning flowsheets to hide rows that are not relevant to the patient.

After some groups at the organization expressed reluctance to change core nursing workflows, the team created a process for stakeholder review that helped validate flowsheet changes.

Once the task force finalized their proposal for a particular flowsheet, they met with representatives from UCHealth’s legal, risk, compliance, nursing administration, and non-nurse clinician teams to obtain sign-off on their modifications. UCHealth’s Chief Nursing Officer Council gave final approval for all changes.

Phase one of the project focused on acute care flowsheets. The team’s changes reduced the amount of time each nurse spent on documentation by 18 minutes per 12-hour shift, corresponding to over 64,800 hours saved annually. 

In phase two of the effort, the team optimized documentation across 19 specialty flowsheet templates, reducing the number of clicks required to complete some templates by more than 50 percent.

The task force administered Net Promoter Score (NPS) assessments before and after making the flowsheet changes to measure outcomes. These assessments use a 200-point scale to measure how likely a user would be to recommend a particular tool to someone else.

UCHealth recorded a 72-point improvement and a 41-point improvement for the two most commonly used flowsheets.

Officials noted that participation from nurses who used these flowsheets every day contributed to the project’s success. Many members of the task force worked in direct patient care, and some of the analysts who built the changes in the system had previously worked as nurses.

In addition to flowsheet changes, the team created an EHR optimization suggestion tool to sustain nurse involvement in enhancing end-user satisfaction.   

Introducing the tool alongside improvements to nurses’ most used flowsheets made it more likely that nurses would remember to submit ideas for workflow improvement, officials said.

Correction 02/22/2022: A previous version of this article indicated that the EHR optimization saved 46,000 hours annually. The article has been updated to reflect more recent figures.