COURSE PRICE: $24.00
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Wild Iris Medical Education is an approved provider of continuing education by the American Occupational Therapy Association (AOTA), Provider #3313. Courses are accepted by the NBCOT Certificate Renewal program.
Content Focus
Professional Issues: Legal, Legislative, and Regulatory
Issues
The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.
Sharon LaDuke, BS, RN, has 15 years of critical care experience in roles such as staff nurse, educator, manager, and supervisor. She also has experience in competence assessment systems and information management. LaDuke is actively involved in the New York State Nurses Association. She writes frequently for local newspapers about nursing issues and has been widely published in the nursing literature on a variety of subjects.
Copyright © 2009 Wild Iris Medical Education, Inc. All Rights Reserved.
Upon completion of this course, you will be able to:
Everyone resists change—unless it's their idea! Yet change is what computers represent to many healthcare professionals, who liked and trusted the paper system they've been using for so long. It doesn't help that using computers in the healthcare system has been given the hifalutin term informatics.
In most hospitals today, nurses, respiratory therapists, physical therapists, occupational therapists, and other clinicians use a computer to record patient information they have collected in the course of providing care. Increasingly, they do it at the same time they are giving that care, before they move on to the next patient encounter (even, perhaps, before they leave the room). Most busy professionals find that this saves steps, errors of memory, and that precious commodity, time.
Technically speaking, healthcare informatics is a blend of clinical science, computer technology, and information management; it involves the collection, storage, retrieval, and use of information for the purpose of providing care, solving problems, and making decisions (American Nurses Association, 2006; Thede, 2003). When functioning optimally, this potent combination of resources can make input easier and access readily available to other members of the healthcare team. In addition, it can potentially support cost negotiations and public health data gathering, among many other things.
You can easily see this trend in many physician offices or clinics: the physician enters information into a computer while interviewing you. At the same time, she enters orders for the lab work you're going to have done and transmits prescriptions to the pharmacy of your choice. She also selects codes for electronic transmission to her billing service, which will in turn transmit the necessary data to your insurance company.
Increasingly, clinicians in all healthcare settings use the computer to find the information they need to evaluate the patient's health status and needs, review orders and diagnostic results, scan the findings and plans of other clinicians, determine what care to provide, document it once provided, and submit data required for reimbursement.
The computer, and the information it stores, is becoming increasingly indispensable to patient safety initiatives. For example, as part of the national movement to reduce medication errors, hospitals are being pushed by regulators and quality groups to purchase and implement computer programs that can eliminate or minimize common causes of medication errors.
An example is a CPOE, or computerized physician order entry (system). With CPOE software, the physician or other licensed provider enters a medication order directly into the computer. This approach to order entry eliminates problems with the interpretation of handwriting, as well as delays in the transcription of the order.
But that's just half of the story. A CPOE also provides the practitioner with guidance. While choosing the desired medication from a list in the computer, facts, crosschecks, and warnings built into the software assist the user in the selection of the correct medication, route, dose, and frequency; alert her to allergies and medication interactions; and help her differentiate one look-alike/sound-alike drug from another, such as Oxycontin (brand name for an opiod analgesic) vs. oxycodone hydrochloride (generic name for the same opiod analgesic), or Humulin (brand name for synthesized human insulin) vs. Humalog (brand name for slightly different human insulin).
Other software-driven medication safety features provide support to both pharmacists and nurses. A pharmacist may be prevented from dispensing the wrong medication, and the nurse from administering it, through the use of "tall man lettering" in the computer and on medication labels (predniSONE vs. prednisoLONE).
Special instructions that show up automatically on the electronic medication administration record (eMAR) used by nursing, such as "do not crush", can be programmed into the computer, which means that the instructions will show up without fail on the eMAR every time the medication is ordered. And, before administration, nurses in an increasing number of hospitals use a barcode scanner to scan both the patient's identification bracelet and the label on the drug that was dispensed, ensuring that the medication matches the order entered for that patient (Institute for Safe Medication Practices, 2008).
The technology that's available in today's market for accessing and using data in a computer is astounding. In just a decade, it has revolutionized the way clinicians work.
In Hospital A, the basic equipment for each nurse is a cart for supplies with a laptop affixed to the top. If the lab posts a critical value (dangerously abnormal result) for an inpatient, a special phone the nurse carries produces an alarm and displays the urgent information on its LED screen.
Respiratory therapists use a handheld computer carried in a pocket to retrieve orders, document their treatments, and, in doing so, "drop a charge" (generate a billing code). Physicians use their Internet-capable cell phones to check patient data from their homes without having to interrupt nurses at work.
In Hospital B, clinicians are able to skip time-consuming log-in procedures and get directly to patient care information with a fingerprint. Radiologists dictate their findings to a computer with voice-recognition software, which then transcribes the dictation for their review and correction.
Pharmacists electronically approve nonemergency medications before they are administered by the nurse, and the nurse obtains the medications from an automated dispensing cabinet filled by (or under the supervision of) a pharmacist, thus ensuring that the discipline most knowledgeable about medications is involved in the process of providing them to patients.
Nurse assistants document patient care with a computer mounted on the wall in the patient's room (or just outside in the hall).
Computers are everywhere in healthcare. If you don't use a computer now to find and enter patient information, you will soon. Why? When did paper charting become outdated? What if you already use a computer to obtain and enter patient information, but the system seems difficult to use, requires you to enter the same information over and over, asks you for information that seems irrelevant, or forces you to enter information from one specific location instead of the place that's easiest for you? Is that what you should expect? Where are we going with all this technology?
Many people are still unfamiliar with computers, so if that describes you accurately you aren't alone. But this course isn't really about the computers. It's about the information we put into them and then use to improve healthcare. Most clinicians know more about informatics than they realize, yet few feel they can discuss it knowledgeably.
A comprehensive treatment of healthcare informatics is beyond the scope of this course. Despite its importance the formal study of informatics is apparently incredibly boring to many clinicians. That's because it's full of technical information and evolving theories, ideologies, and languages that have been implemented in the real world only on a limited basis.
So we can think of this course as Informatics 101, and you can rest assured that only the basic concerns of the working clinician will be mentioned here.
To communicate with others, we must learn to speak at least some of their language. When a shared understanding is lacking, people become suspicious of one another and the task at hand is compromised.
It is not unusual for someone to become annoyed while trying to get assistance from the information technology (IT) department or help desk, when the technician:
On the other hand, it is only natural for a technician to become exasperated when berated by a user who is trying to rush through the problem-solving process. Let's face it, healthcare professionals are not renowned for their patience with computer-related problems.
A delay in performing a single task can have significant consequences for healthcare providers and their patients. The clinician quickly falls behind schedule on dozens of other tasks, sometimes without hope of getting back on track. Or maybe it's possible to get back on schedule, but only by eliminating something important, such as a key patient teaching session, or a treatment, or lunch.
So let's acknowledge that clinicians can be harried and abrupt. Further, they may simply have made no effort to solve their own problem or become technologically savvy in any way. It becomes very challenging for the technician when the customer calling the help desk cannot explain the first thing about the problem and does not know even the most basic computer terms that could provide common ground for discussion.
So you see, the ability to speak the same language in order to break down barriers, make communication more efficient, and get problems solved more quickly is important.
Computer-related language can be challenging. That's partly because:
The concepts and explanations you are about to read are basic. They can help you understand some of the information in this course, and they can help you when calling the help desk for assistance from the IT department. You probably already know some of them, even if you don't think you do. Remember that there may be opportunities to explain your everyday language to IT staff or to alter the language you use so that a technician can understand, just as you would for a patient.
A computer is an electronic device that runs software programs that allow you to input, store, and manipulate data. There are many different kinds of computers. A desktop sits on a desk. A laptop fits in a lap. A notebook is about the size of what you once carried around to jot down patient information. A handheld is smaller still, and a palmtop fits in the palm of your hand.
The desktop is often plugged in continuously, while the other devices are often mobile—that is, wireless. Like your cell phone, they only have to be plugged in to recharge their batteries. Transmitter towers and receiver dishes relay data between wireless devices and the network.
You may be wondering about the term PDA (personal digital assistant). This is a handheld or palmtop computer used as a personal organizer. These little devices can include such tools as an address book, calculator, drug references, entire electronic textbooks, or even a phone. In fact, PDAs and smartphones are beginning to look a lot alike.
What's a smartphone? It is a cell phone with expanded features, typically the ability to access the Internet for email, information, and entertainment. Programs that support healthcare communication functions (eg, accessing data from a remote location) can be loaded (installed) on these devices.
Programs containing sets of instructions that tell the computer what to do are called software applications, "apps", or simply software. They enable a computer to play a movie, run a game, perform mathematical calculations, conduct a lab test, or store patient care information. A computer can't do anything without software.
Your facility's clinical information system (CIS) is a group of software applications that function together to support patient care needs, including documentation, order entry, diagnostic testing, medical records management, and pharmacy, among others. CIS is the same as HIS (healthcare information system). Both are commonly referred to as the information system, computer system, or even simply "the system."
Often, one manufacturer dominates in a particular healthcare setting (eg, Cerner, McKesson, Meditech) and staff use the brand name in everyday speech, as in "Be sure to put that into Meditech." The part of the CIS that electronically stores the documentation, orders, and test results for a patient is the electronic health record (EHR) or electronic medication record (EMR).
In all large corporations, there is a pervasive fear that someone, somewhere is having fun with a computer on company time. Networks help alleviate that fear.
—JOHN C. DVORAK
Computers throughout any large facility are linked together through a network. The reason for connecting computers to the network is to share common information needed throughout an organization. For example, in many hospitals you can view online administrative policies from any desktop; you don't have to be at the computer on the administrative assistant's desk to get to that information.
When you use a computer that is part of a network, it's important to remember that the IT department can identify all the sites you visited, all the games you may have downloaded, all the shopping you may have done—in other words, all of the ways in which rules of the organization may have been violated.
Computers, software, networks—all exist to support the collection and use of data. Data can be thought of as individual pieces of objective information or a collection of information over time in the record of a single patient, or an aggregate of specific pieces of information collected for research purposes.
The person who analyzes data, designs computer-based solutions to challenges related to the data, and then monitors their effectiveness, is an analyst. The skill sets of analysts can vary widely. A clinical analyst is generally one who understands the daily work of clinicians and who assists with such projects as the translation of hospital information needs and current practice standards into the design of documentation screens that clinicians use.
If you have a passing familiarity with the above terms, you can communicate with the IT staff. But here's a tip: Before you call them for help, perform one simple task that will make you feel competent and impress IT with your efforts to resolve the problem yourself: reboot!
Here are a few circumstances where rebooting first may save you a call to the help desk:
To reboot simply means turn your computer off and then turn it on again. The general process is to:
This simple process often "unscrambles the computer's brain" when something stops functioning normally. If the computer won't shut off when you click "shut down" with your mouse, it may be necessary to use the on/off button on the computer case to perform a "hard shut down" by pressing continuously on the button for several seconds. If the computer still won't shut down, you need to disconnect it from its power source. Be sure you pull the right plug. Give the computer a 15-second rest before plugging it back in and turning it on again.
If you perform this off/on cycle and get the system back up and ready to go, half of the time you won't need to call IT at all. The other half of the time, when the IT technician directs you to shut down/restart as part of the troubleshooting process, you'll be able to say "I've already done that. Now what?"
If the rebooting process is foreign to you, practice. Do it a couple of times when you don't have to. Get a trusted and more computer-savvy friend for support while you go through your rehearsal. Then you'll feel confident when you have to perform this task as the result of a problem.
You are not alone if you believe that using a clinical information system for patient care documentation and other forms of communication should save paper. That goal should not be overlooked, even if it has not yet been achieved in many organizations with a computerized documentation system.
Avoiding the use of paper not only relieves the burden on our forests and landfills but also reduces data accuracy concerns; in some cases, information is automatically considered outdated once printed, since each subsequent printing may include new data that has been added to the system.
You may believe that one of the purposes of any computer system is to achieve efficiencies, and you'd be right again. For example, data should be entered by a clinician once, in one place, no matter how many other parts of the system call for the information.
The software system should be able to use automation to find that data, wherever it has been entered, and move it to other parts of the system where it is needed for specific purposes, such as chart auditing or billing. Such capabilities allow work to be completed in a fraction of the time that it once took to perform manually.
Increasingly, the purpose of using a clinical information system is for information management, the control of the collection, processing and delivery of data, and clinical decision support—literally, help with decision making.
Healthcare facilities use information management strategies to get exactly the information needed. Here are some examples:
Hospitals use the clinical information system to provide clinical decision support by providing you with facts, rules, procedures, and other tools when you need them. Whenever possible, these tools should reflect evidence-based practice (EBP), a systematic approach to healthcare delivery that requires the application of current research to ensure that patients receive the most consistent and best care possible (Anderson & Willson, 2008).
There are special software programs called clinical decision support systems; these match patient characteristics (eg diagnosis, age) with an evidence-based knowledge base (research findings and clinical practice guidelines related to that diagnosis) to generate specific recommendations (age-specific tests, medications). These are typically designed for use by physicians; the creation and use of such software for other disciplines is in its infancy (Anderson & Willson, 2008).
Any customizable documentation software can provide at least some decision support for any discipline by translating major research findings into evidence-based practice. For example:
The use of such tools, based on current research and clinical practice guidelines, standardizes care. It facilitates EBP by reducing undesirable variations in clinician practice caused by personal preference or lack of knowledge. It does that by providing decision support.
By the time a protocol makes it into the computer, where physicians are expected to use it, it has typically gone through a number of committees, such as quality, pharmacy and therapeutics, and medical staff.
There's no question that some physicians resent what they consider to be interference in their "therapeutic privilege." Don't be surprised if, in reference to protocols, you hear sarcastic comments such as "cookbook medicine." However, as any good cook will tell you, a recipe is not a guarantee that the meal will be delicious. A recipe is not always used the same way every time. It's a guideline—one that the experienced and knowledgeable cook will adjust according to multiple variables, and one that helps to ensure that a crucial ingredient won't be left out.
So it is with physician protocols. They don't eliminate the need for professional decision making. In my experience, the best physicians have no objection to protocols. Quite the opposite: They tend to be the leaders in establishing such guides. It was once possible for a physician to stay on top of new developments in the medical field, and thus keep up to date, by reading a couple of monthly journals. All that has changed, and amidst the explosion of healthcare information, most physicians appreciate tools that help them remember key guidelines.
The federal government is pushing for electronic health records (EHRs, an electronic version of the paper chart) nationwide within the next few years. If everyone's healthcare record were available, say, via the Internet, from coast to coast, here's one example of how that might benefit patients.
Imagine for a moment that you are in an emergency department far from home. You are seriously ill and can't think straight, but with your social security number and the hospital's unique access code, the ED supervisor is able to get on the Internet and download your entire medical record.
The ED physician is then able to review key information about your medical history and care. If he's not clear about the diagnosis, the computer provides a list of possible diagnoses based on the symptoms entered and prompts additional assessments or tests to make the final determination.
Once the physician has made the diagnosis, the computer provides the latest evidence-based practice guidelines for the treatment of that diagnosis, along with protocols for recommended orders. Using experience and professional judgment, the physician integrates this guidance from the computer into clinical decisions for your care.
As assessment and treatment information is added to your electronic record, imbedded codes assemble a bill that is uploaded to the national single-payer system. Key information about your condition, the treatments that were selected, and the success of those treatments is uploaded to designated research facilities that will analyze data from thousands of patients to create improved treatment guidelines.
A globally accessible EHR may be in the future, but already information management, data-sharing, and decision support are widespread. Continuing with the fall risk assessment scenario, let's look at examples that demonstrate how the data made available by a clinical information system could be used not only by the nurse who completes the assessment, but by others:
Of course, patients slip through the cracks in our fall prevention platforms with frustrating regularity. When prevention fails, real-life healthcare informatics is integral to information management at multiple levels of the healthcare system.
If the patient falls despite the best efforts of the staff, more examples of information management and decision support will come into play. The event will be documented in the computer in a very structured, controlled way, just as with the fall risk assessment. The clinician will answer multiple questions that ask for a specific piece of objective information, selecting the answer from those options offered by the system.
The clinician will have only a limited opportunity to use free text (uncontrolled narrative) to chart additional information deemed relevant. That's because narrative notes, while providing a rich tapestry of information, are not the same as discrete data items. The computer can distinguish between a yes or no, but for the most part, it can't tell the difference between "hit his head" and "wet the bed" in a narrative note. It cannot turn your narrative into data that can be processed.
As the clinician enters information into the system, automated notifications are triggered to others with a need to know, such as the manager. Alerts may appear, informing the clinician of practice guidelines based on current research, or guiding him through policy requirements. These enhance care and reduce liability.
At the department level, your unit manager receives an automated fall notification that was generated by the bedside clinician's documentation. Ideally, the manager or a delegate then performs an investigation, reviewing the data already documented by others and collecting additional data.
The manager's own documentation of the investigative findings will be structured by a tool—a set of questions that is the same for every fall, or even every incident—ensuring that the minimal data needed by the hospital will be provided. The manager also has access to data from previous falls on the unit, and can be on the lookout for trends; such trends can support decision making by suggesting a need for action at the department level. Such actions could include:
At the facility-wide (administrative) level, individuals are in charge of departments with names like quality assurance, performance improvement, and risk management. Falls are a huge liability to organizations, so departments like these monitor the fall data being generated.
The data reveals which units have the highest fall rates; what time of day falls peak; what percentage of falls are associated with the certain classes of medications; and what percentage of the falls occur in association with confusion, a gait disturbance, or an unattended trip to the bathroom. The data available to administrators at the top is limited only by the data entered into the computer system at clinical levels.
Decision making at the administrative level often involves making budgetary provisions for large purchases, such as call systems or beds; revising policy; rolling out facility-wide staff education; creating protocols for better management of confusion; and challenging unit managers to improve call-light response times, ensure that toileting rounds occur, and keep a closer eye on patients with altered mental status.
Data sharing also provides a basis for decision making at the national level. Because of data, falls are now recognized as a leading cause of complications and death. We know that they increase the length of stay and the cost of care. We know who is most likely to fall. And we also know that falls can be prevented with proven strategies.
Armed with such information, and determined to incentivize hospitals to do a better job, the Joint Commission decided to emphasize fall prevention several years ago, adding it to the Commission's National Patient Safety Goals.
The Joint Commission's move had a national impact, because all facilities that are accredited by the agency have had to respond with policies and processes to support the fall prevention goal, which includes collecting data to demonstrate the effectiveness of the fall prevention program.
A clinical information system with structured documentation, automated notification processes, and electronic data-sharing strategies increases the likelihood that falls will be reported in the manner, and through the channels, defined by facility leaders. Some facilities are required to submit fall data to a government or quality body.
In another example of the use of data at the national level, the Centers for Medicare and Medicaid Services (CMS) looked at research data related to falls and fall prevention and made the executive decision that it was no longer going to reimburse your hospital for any additional care required as the result of an inpatient fall. CMS considers falls not only costly but also preventable through use of evidence-based practice guidelines.
This is a very strong financial incentive for all hospitals that care for Medicare/Medicaid patients. Not only will they have to bear the economic consequences of falls; they will also need a way to identify the accounts of patients who have fallen, because special handling of the bill will be required.
Most hospitals are still figuring out how they are going to handle this challenge, but there's no question that the process will be much easier with a clinical documentation system, which allows for the management (control) of information.
In relation to the nationwide attempt to standardize the care of patients with specific diagnoses, such as acute myocardial infarction, heart failure, and pneumonia, hospitals that receive Medicare/Medicaid funds are required to collect data and submit it to quality agencies to demonstrate that they follow key evidence-based practice guidelines, called Core Measures.
Core Measures are interventions that have been proven to improve patient outcomes and reduce healthcare costs. Core Measures for heart failure patients include prescribing ACE inhibitors or blockers, performing an assessment of left ventricular function, conducting patient teaching, and promoting smoking cessation. The data that must be submitted is very specific. That's the nature of information management.
As already discussed, hospitals use decision-support strategies built into clinical information systems to prompt the required care. They use information management principles to guide clinicians through the documentation of exactly the right data. Then they collect the data, using computer automation as much as possible, and submit it using computers and the Internet, not paper and stamps.
Government and quality agencies use the data reported to them in a variety of ways. They create profiles of individual hospital performance, sometimes referred to as hospital report cards, that you, patients and anyone else can view online (USHHS, 2008). These data can help patients to decide where they want to get their care.
The data also informs future research and national healthcare policy decisions. There is increasing discussion of reducing both hospital and physician reimbursement for failure to comply sufficiently with evidence-based practice guidelines like the Core Measures.
As you can see, healthcare in the modern world pivots on the use of computers to manage the creation of specific data, share that data across the facility or across the country, and support decision making at the local and national level. Computers in healthcare are here to stay.
Misconceptions held by clinicians, related to the world of computers, often vary according to their level of experience. You might be able to save yourself some anxiety or irritation if you are aware of some of them. Here are a few.
Computers make mistakes.
Not true. People make mistakes—from the users that input data, to the software writers who do designing or programming, to the manufacturers that create software and hardware. However, the nature of the computer is that it does one thing: math. Not the kind of math that you or I understand, or need to understand. But that's how it works, and it does not make mistakes.
A knowledgeable nurse asked me to fix the software system because it was generating bills that did not cover all the days of service. I asked her for a list of examples, which she provided. She had not analyzed her examples in any way, perhaps because she was thoroughly convinced that the computer was malfunctioning. I was able to demonstrate that the problem was being caused by the users entering the wrong dates in the system. The computer was simply doing exactly what they told it to.
Computers can think.
Not true. Computers can run through an incredible number of math functions in the blink of an eye, but they cannot think. They can be programmed to follow certain steps, but they cannot think. For example, you can attempt over and over to enter the same data correctly without apologizing to the computer for being a klutz; it won't even notice. Computers are wonderful at aggregating (pulling together) data for a human to analyze, but you are responsible for the analysis. And they will give you enough rope to hang yourself, should you decide to misuse them.
I can trust the computer to tell me everything I need to document.
Not true. As we have seen, information management involves structuring the way clinicians answer questions in order to get the exact data needed. If you already have a computer documentation system, you are probably accustomed to doing the same documentation, in the same fields, on the same forms, on every patient every day. The repetition can lull you into complacency, and that's not a good state of mind for a healthcare clinician.
In general:
I have read charts that lacked any indication that the patient was in radiology for three hours, or went to surgery, leaving me to wonder if the nurse knew the patient was gone. I've reviewed charts in which patients with severe dementia, or developmental disorders, appeared to be perfectly normal.
Such "holes" in documentation seem to me to be a fairly modern phenomenon caused by interaction between the human brain and the computer. We become accustomed to being prompted for everything, and to seeing each bit of data separately, because that's how we're asked to enter it. We stop looking at our documentation comprehensively, as we had to when we wrote narrative notes in which we created complete sentences in the order of our choosing. We stop thinking about the big picture.
Don't forget the big picture! You can still pull it all together, even if most of the information you enter is controlled by fields and predetermined answer choices. The equation is simple: everything important that happened, minus information already charted in fields, equals information that should be charted in a narrative note.
I might make a mistake that deletes the whole record or shuts down the system. Sure, you could incapacitate the device you're using if you take a screwdriver to it, pour your coffee on the keyboard, or do something else that isn't predictable. But almost always, when the computer you're using freezes up, it's not because you did anything wrong. Further, you can't erase somebody else's charting, or send the entire record into cyberspace forever. And you certainly don't have the power to make the whole system go down.
I'm worried about losing information I've charted. Yes, you could complete a lot of documentation and then forget to save it. If, at the end of your ten-page assessment, you select Exit instead of Save, for example, the system may not set off an alarm to remind you that haven't filed your information yet. Your personal awareness can prevent this from happening.
Another problem that occurs is related to what's sometimes called a dead zone: an area in which wireless receivers don't function reliably. A dead zone can lead to the loss of information before the clinician has a chance to file it. This is a problem that needs to be corroborated by others, then addressed promptly by IT, which may "drop a wire" in the area (add additional receivers/transmitters to the wireless network).
I must write a note for every patient on every shift. There are many clinicians, including those at leadership levels, who do not understand that information in fields is the equivalent of "notes." There is no difference between entering the words big and brown in the BM descriptor fields and writing a complete sentence that says "the patient had a big brown BM." If there was significant difficulty passing the stool, and the screen for bowel elimination has no computer field for that information, and what you did about it, and what the results were, then that should indeed go in a narrative note.
Don't write a narrative about something you've already documented. That's just double documentation—almost never a good idea. For example, after charting a set of vital signs, there is little value to writing a note that says "vital signs stable." A reviewer will determine the stability of vital signs by reviewing them.
Furthermore, don't waste time trying to come up with a narrative when there's nothing further of any significance. If you documented vital signs and level of consciousness for a cooperative, stable patient at 2 p.m. in the fields for that information, what is the value of writing a narrative note for that time that says, "in bed, watching TV," as I have seen on countless charts, just to put information—any information—in narrative form?
Of course, in the absence of more focused documentation, any note could be of value if something went terribly wrong, such as an elopement or cardiac arrest, if for no other reason that to validate that you saw the patient at that time and he was breathing. But give some thought to when nonclinical information is relevant. For example, most of the time, charting visitors adds nothing. But for infants and children, behavioral health patients, or in the case of family feuds, such information may take on new importance.
I can do anything I want in the computer and no one will know. Generally not true. You leave a fingerprint everywhere you go in the system.
Here are some common mistakes:
I don't have time to find out what this question means. In the electronic documentation world, many facilities use strategies to make charting quicker and easier. In one common approach, a single question is designed to cover a lot of territory by using the phrase "within normal limits" (WNL) within the text of the question. Example: an assessment field may read "Range of motion WNL."
When facilities make reference to normal limits, they are expected to define those limits somewhere, and they typically do it in the information system, not in a policy book on a dusty shelf. In this case, the definition of "WNL" for nurses may be "No changes in last six weeks; no problems with activities of daily living." The definition that applies to this same question for physical therapists may be vastly different. Be sure you know the definition of "normal limits" before you answer the question. Generally speaking, don't answer any question you don't understand.
I have to pick one of the answer choices offered for each documentation question, even if none of them seem correct to me. This dilemma is usually related to one of two things: a lack of information on your part, or imperfect design of the question and its answer choices. Ask a colleague for help. If you still feel there is no correct answer choice, skip the question and address it in a "comment field" or other place where you can enter free text (write a narrative description).
Ideally, you will share your experience and thoughts with the department manager, the clinical analyst, or someone else who is involved in making improvements to the system. Following a documentation system without question is no more recommended than following policies without question.
The clinicians in my department can't use the computer to document because…. A variation on this is "the documentation in my department is completely different from [that of other department]." Typically, this is a nursing complaint. While it's true that various nursing departments have special needs and cultures, care varies little from one area of the hospital to another, from one hospital to another, and from one state to another, if it's being done according to standards of practice. In reality:
Adapting the online charting system to a new unit is a two-way process that involves modification of care processes to accommodate the EHR, and vice versa (Byrne, 2008).
The patient record should either be entirely electronic or entirely on paper. There can be some problems with a so-called hybrid record, but a fully online system may be impossible due to:
Before moving a process online, it must be fully understood with careful consideration given to the manner and frequency with which data has previously been viewed, and understanding of how the switch may affect that.
For example, I have seen multiple hospitals struggle with the switch from an intake and output worksheet that hangs on the patient's bathroom door, where both the nurse and nurse aid make entries throughout the shift, and which the nurse can instantly analyze every time he walks into the room. At the end of the shift, the nurse tallies the totals in the computer system and conducts a final review of fluid balance issues. All of this fits the workflow.
If there is a desire to eliminate the worksheet, clinical leaders must carefully consider who can enter the data in the system throughout the shift, how the nurse is going to see it, how often, and how the new approach will jibe with normal workflow, in order to ensure the same oversight of the patient's fluid balance.
Research indicates that in the early stages of implementing an online documentation system, nurses appreciate its convenience and reminder functions. However, as time goes on, they become aware of disadvantages such extra workload, insufficient training, content design problems, and poor interdisciplinary cooperation (Lee, 2007).
The biggest disappointment that clinicians encounter in the use of a computer documentation system is often related to the issue of time. They tend to think they will be able to complete documentation more quickly than they did on paper. In fact, when all is said and done, they are sometimes spending more time documenting than before.
If that's the case, it's important to recognize that it could be because they are documenting more in support of patient safety, quality care, billing, and other initiatives. Yes, they are spending more time documenting, but they are accomplishing a lot more and supporting more important goals. This may be invisible to the clinician who is creating the data because he or she is not the person who will be using the data. Time concerns can, of course, be caused by a system that is complicated and inefficient, or related to policy issues and the problems cited above.
Software applications can be incredibly expensive. A single new type of software can easily cost hundreds of thousands of dollars, and your hospital doesn't have the resources to purchase as many new applications as it would like. So don't get mad or think that the hospital doesn't appreciate your special needs because it isn't purchasing the "best of breed" application that has all the bells and whistles you desire.
Hardware—desktops, laptops, handhelds, printers—is comparatively cheap. Wasting the time of staff who need hardware to complete required patient care tasks is incredibly expensive in terms of staff dissatisfaction. Creating delays is expensive in terms of patient satisfaction. There is no excuse for you to have to stand in line for your turn to use a device that you need to do your work, any more than there is an excuse for not having enough IV pumps in the house.
Another hardware problem can be inadequate maintenance and management. For a variety of reasons, you may be plagued by wireless equipment with bad batteries, desktop screens that seem to change every day, and printers that don't print.
If your work is being slowed and complicated by equipment issues, go through organizational channels to see what can be done to address the issue. Team up with several other staff members; there is power in numbers. Develop your arguments; gather evidence and document it.
Find out if other departments are having the same difficulties. Then go to your manager to discuss the problem, if you haven't already. Ask how the manager thinks the problems can be addressed. There may be other leaders or committees you can go to, but it's almost never right to escalate an issue without letting your manager know it exists and that you plan to do something about it.
A clicinical information system allows multiple disciplines to access the EHR simultaneously, and from multiple locations. The respiratory therapist can be charting a treatment at the bedside at the same time that the nurse aid is documenting a meal in the hall, the physician is looking up lab results from the library, the social worker is reviewing the notes of the case manager, and the student nurses are studying the chart at the nurses station.
A CIS should display the key information you need to make patient care decisions in a format that's easy to access. For example, you should not have to press thirty keys to get to the part of the system that will give you the patient's latest blood glucose level. You should not have to press ten keys to see the most recent blood pressure, then ten more keys to see the last one. The system should also make this data accessible to physicians in remote locations, such as offices, restaurants, or their auto.
Here are some examples of tasks commonly accomplished electronically. The computer:
Although your facility won't have software specifically designed for decision making by your profession (unless you are a physician), any basic system can be customized in-house to provide you with evidence-based guidelines and other forms of information that help you know what to do and what to document. To accomplish this, a hospital needs adequate resources, such as a medical librarian, staff who monitor for new evidence-based practice recommendations, and a clinical analyst to translate them into clinical practice guidelines.
It is your responsibility to stay on top of key changes in the practice of your profession. For example, just because your facility does not yet have a policy to ensure that urinary catheters are removed as soon as possible, you are not excused from knowing that urinary tract infections (UTIs) are a major complication directly linked to urinary catheters. You are not excused from addressing the catheter with the physician every day to ensure that there is a valid reason to continue using it (eg, for fluid management in a critically ill patient, but not for urinary incontinence).
To give specific examples, the CIS should:
These are just some specific examples, but the concept can be used over and over. Often, users can bypass safety features, exposing patients to harm and themselves to liability. An example is scanning something other than the patient's ID band, and/or something other than the package to be opened, during medication administration.
As future lawsuits are settled, it will become evident that the courts have little sympathy for clinicians who make errors as a result of intentionally bypassing safety features that, used correctly, would have protected the patient from harm.
Through information management and decision support, the CIS should:
Workflow takes into consideration what you do, when you do it, the processes you follow, and the resources it takes to support those processes. As you go about your daily tasks, the documentation screens you are expected to complete should reflect the way you work, mirroring not only what you know, but when you know it.
For example, in an acute care practice, a nurse will typically be expected to document a fairly comprehensive assessment near the beginning of the shift. The computer form the nurse uses for that purpose should prompt her to enter information that reflects what she knows about the patient at that time (mental status, breath sounds, bowel sounds).
Later in the shift, the nurse will be able to look back on the previous hours and report on many other important events that happened during her shift—bowel movements, urinary catheter insertions and removals, and changes in resuscitation status, to name a few. There should be a simply way to capture those key events near the end of the shift without having to return to a long, ponderous form and press the Enter key fifty times.
A common design mistake is to create a system that is overdone: too much, too fancy, too complicated. This has little to do with the software itself and more to do with the planners, design team, and builders, who are often among the sharpest people in the institutions and have worked long and hard on the system design.
Systems design—deciding what entries should go in tables; selecting and labeling documentation fields; designing screens; identifying data needed for reports; making all the pieces fit together and run smoothly—is critical to the efficiency and acceptance of an online documentation system. Serious design flaws undermine the ability of the facility to manage information. And, if clinicians refuse to use the system as intended because it's too cumbersome, then the system will not be able to provide decision support.
People who are new to online documentation systems may not fully recognize that simpler is better. With no prior experience, it can be difficult for them to recognize simple vs. complex. They will have high aspirations for the system they're creating; they want it to be better than every other system. They're motivated, they're smart, they have energy, and they believe they can achieve that goal.
It doesn't help that the computer sings a siren song to designers and the various stakeholders who are drooling over all the data they imagine they can get: it seductively whispers "I can do anything. I am limitless." The problem is that staff are not limitless and what is more, staff members are supposed to be spending their time with patients.
Staff know the difference between data entry that is useful and system requirements that waste precious time. And staff are pretty predictable: they want a system that works easily and makes sense, the simpler, the better. As everyone eventually learns, a simple system that staff are able to use correctly is superior to a complicated system that the person in the trenches finds difficult to use.
It may be of value for design teams and team leaders to define goals for the system they are creating—not only their own goals but also the goals of a wide variety of users. They need to define the users and the patient population before making decisions that set the tone for the system's complexity. For example, is the system primarily for a large, research-based oncology center serving patients participating in clinical trials? That situation may call for complexity that is simply not necessary in other settings.
Apart from complexity, when it comes to pure workload even the smallest decisions eventually have a cumulative effect. Eliminate or add a question here, a keystroke there, an answer choice over there, and soon it adds up to a significant amount of time spent studying choices, poking around in the system trying to find things.
Let's look at a few common features of the too-complicated documentation system.
Too many questions. The implementation of online documentation will lead to the launch of many data collection projects, which will increase the amount of time spent peering at a computer instead of patients. Because so much information is mandatory, it is incumbent on hospitals to minimize the collection of data that is outdated, irrelevant, and unused. The aggressive identification and elimination of such data should be one of the formal goals of the design team.
Administrative support may be needed to help the team carry out this element of the plan, because there are a lot of "sacred cows" out there in the system—information nobody really uses, but nobody wants to give up. Risk management insists all tattoos be documented because that was a question that was popular when HIV was first discovered. Quality management thinks all patients must be asked if they or their kin have sickle cell anemia, even though less than a thousandth of the region's population is African American.
Anesthesiology clings to a lengthy latex allergy assessment instead of a single direct question because ten years ago a patient had a latex reaction in surgery. To make things worse, the twenty-question tool isn't on the pre-op assessment, conducted on the patients who have surgery: it's on the general admission assessment, where it slows down the completion of documentation for all inpatients, even though 95% of them will not be going to surgery.
Too many pop-ups and warnings. Analysts speak of pop-up fatigue. Eventually, the user's brain ignores the very safety warnings created to engage attention. Pop-ups should be used sparingly.
Too many choices. In the selection lists for problems, goals, interventions, and care plans used by clinicians to assemble relevant documentation structures, there may be hundreds of care plans and thousands of goals and interventions. The average user cannot take in all of this; cannot spend enough time with 300 care plans to become familiar with them; cannot differentiate among ten interventions that sound alike; cannot manage a list of fifty interventions for a single patient's care.
Redundant data entry. Staff may be entering the same information repeatedly because the person who wrote the policy that requires this does not understand how the online documentation system is set up, works, or is used, or has not revisited the policy since the system was implemented. That problem can be rather easily fixed.
Duplicative charting could be due to poor design of documentation structures: In one hospital, I found 37 bowel and urinary elimination fields on 12 different screens. More problematic, duplicate charting could be due to lack of interoperability, in which two software systems don't speak the same language, and the same information has to be entered in both (a problem no hospital would have if it had an unlimited budget).
Standardized languages (SLs). These are not required for documentation of patient care. They tend to be poorly understood by staff, and even less by patients. NANDA/NIC/NOC, the Clinical Care Classification System, and other SLs may be of value in a masters degree informatics program or a research setting, but the usual hospital care setting is not an academic classroom or a research lab. Most hospitals are struggling to save time and make things easier for clinicians. Depending on how they are used, incorporating SLs into the system may be at odds with that goal.
Some SLs are very useful on a practical level as a resource for screen design. Depending on the software, they could also be used to organized evidence-based practice guidelines. But if the purpose of using an SL is to assemble professional-looking care plans in the format taught for so many years in nursing school, it is critical to first perform a realistic assessment of how care plans are being presently used in the facility.
Imposing a new and more complicated language on a nonfunctioning process will not resuscitate the process, and there may be a much easier way to have a working and valued electronic plan of care that does not add to the workload of clinicians, but actually helps them.
Problems such as these are not always easy to avoid, but they are easy to identify after the fact when it becomes clear that:
Failure to identify the working care plan. Many hospitals continue to use traditional care plans—interdisciplinary, but still in the old style used by nursing. Such a format is not required by regulation.
These traditional care plans often serve no purpose except to create busywork, because staff don't have time to individualize and update them, and don't consult them to find out how to care for the patient. If this is the case (and it is at many facilities) it should be openly acknowledged so that system planners don't spend a lot of time building care-planning features into the computer that are not working on paper.
If the traditional one-document, centralized care plan is not really driving patient care, what is? Many facilities have a combination of other documents and processes that constitute a "working" care plan. This set of tools serves the purposes that the traditional care plan used to serve.
Example of a working care plan: orders plus MAR plus problem list plus goal sheet plus handoff plus shift report plus interdisciplinary rounds. Hospitals can rewrite their care planning policy to reflect what they really do, and what really works. They can drop the traditional care plan if it has no value. They can acknowledge that clinicians obtain the information needed to guide safe and individualized care from many sources that are continuously updated by the computer, and not from a single, centralized master form that someone has to revise manually (LaDuke, 2008).
System design without knowledge of needed data. If nurses and other staff don't document the exact data needed by others (eg, infection control, quality management, smoking cessation, abstracting), the need for the facility to continue manual charting for the collection of data is assured. That's an unfortunate outcome for any facility that has invested in electronic health records. Knowing exactly what information is needed is the start of the analytical process that determines if and how this data can be collected from the user.
Missing voices at the table. Absence of clinical users from the design team is an important problem. Absence of an experienced documentation design analyst is another—one that can't be remedied simply by making site visits to see how others have designed their system.
Self-affirmation. Objectivity is lost when the evaluation of the documentation system design is done by those who designed and built it, instead of by those who have to use it. Customer satisfaction surveys can be useful in obtaining anonymous feedback.
Even a documentation system that was initially streamlined can become bogged down, over a period of several years, with patches added to fix an organizational problem here, a regulatory requirement there. Analysts sometimes say the life cycle of a system is ten years. No matter how good it was initially, it's going to need an overhaul after a decade of use and abuse.
The subject of healthcare informatics is vast. With a basic grasp of the concepts of information management, decision support, and with the sharing of data at many levels, clinicians may be better able to understand why the system they use for documentation is designed the way it is. With an understanding of a few concepts about the pros and cons of system design, they may be better prepared to discuss their ideas for improvement.
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Byrne M. (2008). Finding common ground for information technology staff and clinicians. CIN: Computers, Informatics, Nursing 26(3):12528.
Institute for Safe Medication Practices, http://www.ismp.org, last accessed December 8, 2008.
LaDuke S. (2008). Death to nursing care plans! American Journal of Nursing 108(6):13.
Lee T-T. (2007). Nurses' experiences using a nursing information system. CIN: Computers, Informatics, Nursing 25(5):29499.
Thede, L. (2003). Informatics and Nursing: Opportunities and Challenges. Philadelphia: Lippincott Williams & Wilkins.
U.S. Department of Health and Human Services, http://www.hospitalcompare.hhs.gov, last accessed December 8, 2008.
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