Literature review on clinical systems on outcomes and efficiencies within the context of nursing practice and healthcare delivery

           Electronic health records (EHRs) have become so widespread that they are standard in healthcare, but they have come under intense scrutiny in the past decade. Now that the widespread adoption and implementation of EHRs has occurred, researchers are looking at the way EHRs have influenced nursing education, workflow, care and ethics and many issues have been raised. Lavin, Harper, and Barr (2015) of the Online Journal of Issues in Nursing looked at EHR design and processes. Varpio, et al. (2015) of Medical Education wonder how the way information is displayed on EHRs affects the cognitive functions of clinicians who use them such as through the chronology of a patient’s health history and how the changes affect clinical reasoning. Vossebeld, Puik, Jaspers, and Schuurmans (2019) of BMC Medical Informatics and Decision Making discuss how ways to make EHRs more time-efficient for nurses have led to abandoned attempts to remedy the inefficiencies. Finally, McBride, Tietze, Robichaux, Stokes, and Weber (2018) of the Online Journal of Issues in Nursing discuss ethical implications raised by the use of EHRs. In this literature review, these are the issues that have been considered.


            An issue that takes time to understand is the way information and communication technologies such as EHRs change the way humans conceive of and use information. In a study done at a pediatric academic health center between 2009 and 2011—the early days of EHRs—Varpio, et al. (2015) collected and analyzed data from healthcare teams using paper patient charts. Then once the EHRs were launched, they collected and analyzed data from the same healthcare teams. They found that clinicians who used the EHRs at this point were not receiving adequate training on their use, but perhaps more interesting is the fact that EHRs affected the way clinicians reasoned about patient care and the way their clinical reasoning skills developed while using the data from EHRs (Varpio, et al., 2015, p. 477). Using the paper charts, the clinicians felt as if they had a narrative about patients’ medical histories. With the EHRs, information is presented textually and numerically but not chronologically.

            Issues of cognition and reasoning surrounding reasoning skills associated with electronic data is an issue in many professions, but nowhere is it more critical than in healthcare. Narratives help clinicians reason about a patient’s condition. EHRs can be designed to include more of a narrative format and that is what Varpio, et al. (2015) recommend as a solution to the problem. However, many EHRs often reflect the coding practices of individual vendors of the program, which often causes them to be introduced in healthcare settings only to be quickly abandoned for incompatibility (Varpio, et al., 2015, p. 484). If vendors of EHRs would find a way to better incorporate the input from healthcare professionals this practice of high cost waste would not continue.

Design Improvements

            Vossebeld, Puik, Jaspers, and Schuurmans (2019) also talk about design flaws in EHRs. The specific device they discuss though is a mobile electronic medical record device known as an MEMR. This device had its first clinical test in a hospital in the Netherlands. An MEMR is used to enter patient information into the EHR/EMR at the bedside with a mobile device that would save time charting the information later in the shift. This would allow nurses more time with patients, thus increasing the quality of care.

            The issues with the MEMR arose because of disconnects or mismatches in the design process. One problem arose when the Wi-Fi connection blank spots shut the system down. Nurses should have been able to log-in once at the beginning of their shift and then use a 4 digit code thereafter. However, because of the spotty wi-fi, they continuously were required to re-log-in which took time from patient care (Vossebeld, Puik, Jaspers, & Schuurmans, 2019, p. 6). Because of these insufficient wi-fi errors, some data was lost. Another issue was that the MEMR did not allow nurses to enter some types of data such as fluid balances, glucose measurements, or the Glasgow Coma Scale function used by neurology units. The surgical unit wanted to use cameras to document wound healing, but were denied due to patient privacy concerns (Vossebeld, Puik, Jaspers, & Schuurmans, 2019, p. 7). Finally, a big concern was the hygiene of the mobile device that was carried around from patient to patient (Vossebeld, Puik, Jaspers, & Schuurmans, 2019, p. 9). The MEMRs were abandoned not long into the trial because of these and other issues concerning them.

            While not all the issues associated with the MEMR were necessarily design related, many of them were. The ideas of how nurses wanted the device to operate was not, or could not, be translated into a functionally designed device that achieved the objective of more efficient and improved patient care. Vossebeld, Puik, Jaspers, and Schuurmans (2019) say that the feedback and redesigning should have been an ongoing process. They feel the device could be useful if it were designed with the nursing process in mind.

Frustrations and Improvements

            The MEMR issues were not the only ones related to the implementation of EHRs. Lavin, Harper, and Barr (2015) discuss the importance of including nurses in the design process. They say that nurses tried to express their concerns but “there was no available taxonomy to describe EHR-related difficulties” (Lavin, Harper, & Barr, 2015). Initially, this was true since EHRs were new to everyone involved. They suggest several improvements that could be made including more information in the EHRs regarding medication interactions and possible outcomes, font size, readability;  and “mak[ing] the nursing process more transparent in the EHR for each patient problem requiring nursing care” (Lavin, Harper, & Barr, 2015). Some suggestions they have include voice activation and natural language processing so documenting in EHRs can be synchronous and take up less of nurses’ time during their shifts.

Ethical Issues

            Ethical issues permeate healthcare and EHRs are not immune regardless of their seemingly neutral origins. While McBride, Tietze, Robichaux, Stokes, and Weber (2018) believe that EHRs are an overall improvement for the healthcare field, ethical issues that were not foreseen have arisen. These researchers mention the moral stress of providers who confront such issues as clinical decision support (CDS), which is an aspect of some EHR systems. CDS will alert when evidence-based protocols are not followed. However, “these same formulaic alerts can present challenges to clinical decision making for clinical teams working with an actual patient, raising practical and ethical considerations” (McBride, Tietze, Robichaux, Stokes, & Weber, 2018). They cite a case study where a nurse knows that the symptoms an ED patient is displaying are symptoms of heart failure and the suggested protocol would be contraindicated. The nurse knows that the CDS should not be followed in the situation, but if providers do not follow the CDS, electronic quality measures will be affected. These are often associated with value-based purchasing payer models meaning the hospital could be penalized for not following the CDS even though it is the wrong intervention for the particular patient (McBride, Tietze, Robichaux, Stokes, & Weber, 2018). This is one way EHRs pose ethical dilemmas for healthcare providers. There are others such as nurses developing alarm fatigue when EHRs alert to issues that nurses know are not relevant or applicable to certain patients.


            Because of issues with clinical reasoning, design flaws and ethical considerations, EHRs have proven to be a challenge for many healthcare providers. However, they are still seen as innovative and necessary for progress in patient care. Now the challenge will be for designers to design the clinical system so that these types of issues are minimized The challenge for healthcare professionals is to be assertive about their input into these designs.


Lavin, M., Harper, E., & Barr, N. (2015). Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings" . Online Journal of Issues in Nursing, 20(2). Retrieved from

McBride, S., Tietze, M., Robichaux, C., Stokes, L., & Weber, E. (2018). Identifying and Addressing Ethical Issues with Use of Electronic Health Records. Online Journal of Issues in Nursing, 23(1). Retrieved from

Varpio, L., Day, K., Elliot‐Miller, P., King, J. W., Kuziemsky, C., Parush, A., & Rashotte, J. (2015). The impact of adopting EHRs: how losing connectivity affects clinical reasoning. Medical Education, 49(5), 476-486. Retrieved from

Vossebeld, D. M., Puik, E. C., Jaspers, J. E., & Schuurmans, M. J. (2019). Development process of a mobile electronic medical record for nurses: a single case study. BMC Medical Informatics and Decision Making, 19(1), 1-12. Retrieved from