Documentation Guidlines: Part 2

Continuing the discussion of developing documentation guidelines; our team conducted an environmental scan to learn what others have done and were doing to address the issue of documentation burden. I was pleased to discover a number of articles written related to issues surrounding documentation burden.

There were common themes in the literature. For example, each reported that they were responding to documentation burden as a nurse dissatisfier. All expressed how they examined the problem and associated issues. Most reported their assessment involved metrics such as click, query, and screen counts.  Others reported metrics related to time to complete a screen or function such as the admission assessment.  Never did we find anyone describing their assessment of the nurse's documentation level of effort as good or expected.

A common tactic to combat documentation burden in the literature was to develop guidelines for reviewing EHR queries requests. As we examined our facility we noticed a trend to have queries added in reaction to practice issues. It seemed we were attempting to teach nursing or somehow control for bad actors by adding a query to "guide" the user.  We realized that is not the purpose of an EHR and we had unwittingly contributed to our documentation burden with this practice.

We decided to develop guidelines of our own to inform and review both new and existing EHR queries. Queries requests would need to be evaluated against guidelines.  The draft guidelines our clinical informatics group put forth are:

• Assume that nurses are ethically and clinically competent
• Collect data that inform clinical care and supports nursing workflow efficiencies (nursing care planning, clinical decision making or nursing outcomes).
• Construct data and queries to support evidence-based practice
• Automatic data capture whenever possible for bedside devices (Cardiac monitors, ventilators, IV pumps, etc)
• Required by mandatory regulations 

I would be interested if anyone would be willing to share their guidelines or wish to comment on our draft.

Documentation Guidelines

Documentation is a mainstay of nursing practice.  Even as students we were taught to record the clinical activities and observations.  Nursing notes can be traced back to Florence Nightingale. Clearly, nursing documentation has been around a long time.  We use nursing documentation to identify clinical trends and patterns that inform nursing care planning and decision making. As we adopted the electronic health record (EHR) we began increasing our data collection with the promise that electronic data would be usable and shareable. Unfortunately, that assumption hasn't proven to be true. Some have described today's health record as data rich, information poor and given this phenomenon the name DRIP Syndrome (Goodwin, 1996). 

I find this phenomenon present in the hospital where I practice.  My colleagues have reported they too experience the frustration of DRIP Syndrome. It seems that just because we could add data fields; we did.  The result is an explosion of data capture requirements creeping into our EHR with little improvement in clinical outcomes or observations. The unintended consequence of randomly adding data fields is the reduction of the clinical nurse's capacity to provide direct nursing care.

The purpose of documentation was never to replace time spent in clinical care. Documentation was to collect and trend clinical data that informed observations regarding successful therapies and outcomes. How do we get back to meaningful documentation that informs nursing care planning and decision making? The approach our facility is taking is to establish guidelines that data capture must meet before it is added to the EHR.  Additionally, we plan to establish a review process to determine if an existing data field continues to meet the guidelines.  I am wondering if anyone else is working on a similar project?  I plan to share our work and hope others will do the same. 

Reference:
Goodwin, S., (1996). Data rich, information poor (DRIP) syndrome: is there a treatment? Radiology Management May-Jun;18(3):45-9.

Documentation Burden

Recently, I have become aware of EHR documentation burden. This was raised at a clinical informatics meeting by frontline nurses who are members of this group. Since that time, I have come across articles, commentaries, and interviews with nursing leaders where this issue is mentioned. I have even found a 2009 document published by AHRQ entitled Impact of Health IT on Nurse's Time Spent on Direct Patient Care. Yes, nearly 10 years ago AHRQ anticipated this unintended consequence of EHRs. Last year Patient Safety Solutions published a blog "How Much Time Do We Actually Spend on the EMR?" This post reviewed recent studies measuring the time nurses and other clinicians spend documenting. One study by Higgins (2017) found that “Overall time in the EHR (documenting, reviewing, and medication preparation) of about 3 hours per 12-hour shift was corroborated by observations and the automatically generated computer time stamps.” I have to wonder, about the extensiveness of the unintended consequences for the clinicians and how much of the issue is related to how EHRs were implemented?  I know my organization has begun to examine this issue and the impact on our nurses at the bedside.

Moving forward as I scanned the literature, I found several health systems have attempted to address this issue through optimization projects. EHR vendors offer optimization services to assist their clients to address documentation burden. There is growing consensus that organizations created EHR screen builds that have nurses collecting all types of data and in some cases, the data capture isn't nursing related. For example, how does documenting a patients' belongs inventory inform nursing care or clinical decision-making? Are nurses the right person to collect this data? Additionally, as we create numerous queries, we often use unstructured homegrown data labels that contribute to the issue of interoperability. These data fields have unclear nonstandard data definitions. In our organization, we have created admission documentation demands that take nurses away from clinical care and require at least an hour to complete a single admission using nonstandard data field.

As I think more documentation burden, I am finding two components to consider: a) data capture and b) data foraging. Both, data capture (requirements for data recording) and data foraging (looking for the data you need to inform clinical decisions) contribute to documentation burden for nurses. On a positive note, organizations are beginning to create guidelines that can be used to evaluate if the data capture requested should or should not be included in the EHR for a nurse to spend clinical care time collecting.  I am reaching out to those organizations in hopes to learn more about the outcomes of their journeys.  Additionally, I have become aware that American Nursing Association and the Office of the National Coordinator have begun a project to explore this issue. 

EHRs were thought to help with information processing and clinical data sharing. The belief was that EHR would create usable data to support clinical activities and get the nurses back to bedside care.  Have we missed the mark? Anyone working on these issues? I hope to share our organization's journey, as we work to address the documentation burden we are attempting to overcome.  I invite you to share your experiences.  


References:

Higgins LW, Shovel JA, Bilderback AL, et al. Hospital Nurses' Work Activity in a Technology-Rich Environment: A Triangulated Quality Improvement Assessment. Journal of Nursing Care Quality 2017; Published July/September 10, 2017, 32.3 pages 208-217.

RN-BC Opening Doors

Board Certification

For the past six months I spent time preparing for the ANCC Informatics Nursing Certification exam.  I am pleased to report, I passed! 

Honestly, my decision to take the exam was the longest part of my journey. I believed that graduate informatics nursing education was enough; so for 5 years I avoided the certification process thinking it didn’t apply to me.  It was last year that I accepted the challenge to sit for the exam because I realized that the certification provided a spark to have a conversation with others about informatics nursing specialty.  I am leveraging my recent certification as an opportunity to discuss the unique skills and knowledge that an informatics nurse specialist brings to projects and the workplace.  These conversations inform others about the informatics nursing specialty and as a young profession it is important to tell our story with a clear voice.

To learn more about the application process for certification visit the ANCC website.  There are a number of helpful tools to support preparation that achieves a successful outcome.  My personal approach was to participate in an online review program, and to use a review text. Additionally I found this website very helpful to create my own practice exams www.quizlet.com. My reward has been a number of occasions to explain and discuss the role of the informatics nurse. These discussions resulted in me finding more opportunities to be engaged with a wider range of project that involve process improvement of system where data and information sharing activities are key. 

Copy and Paste: The unintended consequence of convenience

Copy and Paste, also known as cloning, appears to be a seemingly harmless convenience for busy clinicians. According to the America Health Information Management Association (AHIMA), 74 to 90 percent of physicians use the copy/paste feature when recording information in electronic health records (EHRs), and between 20 to 78 percent of physician notes are copied text (AHIMA report.) Clearly, many leverage this convenience that EHR software affords to busy clinicians.  But, is it a safe practice?

Over the past 10 years, I have heard EHR users hail the timesavings gained by using the copy and paste feature.  I have also seen egregious errors of all types introduced into a medical record by this same practice, including, for example, a situation where an original wound assessment was copied forward for every reassessment so that it appeared that the patient’s wound never improved or healed. Another witnessed example of copy/paste gone awry is where a patient’s historical family condition migrated to the patient’s active problem list and a consultant began treating a condition that was not present for this patient. I’m thinking you might also have observed unimaginable errors. My list of examples is long and my experiences have made me personally reluctant to activate the copy and paste feature within an EHR.  I have experienced this conversation many times with clinicians who argue that we should not punish them by withholding this timesaving convenience because of a few bad actors. The truth is, in my experience, these individuals are not bad actors; they are busy and caring professional clinicians that were set up to fail.  For that reason, I feel we, as specialists in the use of health information, need to implement systems that make it hard for the clinician to do the wrong thing and easy to do the right thing. Using copy/paste inappropriately can result – and has resulted – in redundancies and errors that impact safe patient care and, therefore, we need to proceed with caution.

AHIMA has been raising concerns about this practice for years and recently released an advisory notice on March 17, 2014 stating that the use of copy/paste should be permitted only when "strong technology and administrative controls” are in place.  This notice recommends specific steps for the following groups:

• Industry stakeholders
• EHR developers
• Public sector
• Healthcare provider organizations

In the end, there are no absolutes.  I believe that users of the copy/paste feature should weigh the efficiency and timesaving benefits it provides against the potential for creating inaccurate or misleading documentation that negatively impacts patient care. The following are the AHIMA recommendations for the healthcare provider organization:

• Develop policies/procedures addressing the proper use of the copy/paste feature to assure compliance with governmental, regulatory, and industry standards.
•  Address the use of features such as copy/paste in information governance processes.
•  Provide comprehensive training and education on proper use of copy/paste to all EHR system users.
• Monitor compliance and enforce policies/procedures regarding use of copy/paste and institute corrective action as necessary.

As informatics nurse specialists, we are ideal candidates to help healthcare provider organizations implement these recommendations.

To review the complete AHIMA advisory notice visit:

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf

Vendor relationships require leadership

Vendor relationships require leadership

It is time to upgrade or replace existing information software.  The executive team has approved and funded the project. The purchase orders are issued and the vendor has assigned a “PM” (Project Manager) for your project. The next steps are to organize the project timeline and craft the details of the project plan.  As you work through this process you note that vendors have an advantage because they have a team of individuals that do only project management for this specific software implementation.  My experience has been that the vendor PM will often come in with the intent to lead the project, when in fact, the project is your responsibility.  The challenge becomes how to leverage the vendor’s expertise and experience in a cooperative way while maintaining your role as leader of the project.

I have found there is a range of ways you can maintain control of your project when the vendor PM attempts taken over. These strategies rely on leadership and management techniques; good communication skills; and the ability to influence others and articulate system requirements. Lastly, applying emotional intelligence (EI) to the situation is extremely helpful.  EI is the ability to read a situation, know the team members, know oneself, and respond accordingly. It is important to include the vendor as part of the team and solicit their input.  It is also important to present yourself as the project lead.

Remember that, in any relationship, heavy-handedness often comes with a price. Fixing issues and problems by issuing threats of additional penalties may work in dire situations with problem vendors, but is not a universally recommended mode for achieving a successful implementation.  Attributes that I believe support successful vendor relationships are: accessibility, candor, toughness, intensity, likability, humor, integrity, follow through, reputation, presentation, and clear communication.  I also find that using a blend of leadership and management techniques with communication and EI skills will support project success.  I have found these ten actions help:

1.   Have a clear vision of the outcomes, and communicate that vision so others can grasp it

2.   Focus communication to create understanding and clarity of the project expectations, roles, tasks, barriers and outcomes

3.   Apply EI to read situations, and personal strength to take a stand as needed

4.   Use abilities to connect and work with a range of people, professions and personal styles of communication

5.   Set and monitor deadlines and project timelines

6.   Work to  gain early and continuous buy-in from stakeholders  around project targets and goals

7.   Negotiate work agreements, assignments, and day-to-day issues resolution

8.   Articulate the plan and steps to others in a clear and concise manner with frequent updates

9.   Engage others in the process of problem resolution

10.    Be flexible and willing to adapt to changes while helping others to adapt to changes as well.

Whenever project management is required, whether for a small project or a large and complex situation certain key attributes and actions tend to be universally recommended to help achieve project success. I have found that, by tailoring one or more of these to the current effort, project steps are much smoother and project success is more likely to be realized. 

Nursing informatics: It is what we know that matters

In the 2008 ANA Scope and Standards, you will find NI defined as “ Nursing informatics (NI) integrates nursing science, computer and information science, and cognitive science to manage, communicate, and expand the data, information, knowledge, and wisdom of nursing practice. Nurses trained in NI support improved patient outcomes through their expertise in information processes, structures, and technologies, thus helping nurses and other care providers to create and record the evidence of their practice” (ANA, 2008).  As an Informatics Nurse Specialist (INS), I do much more than support patient outcomes through my expertise in information processes, structure, and technologies.  The industry has also recognized that it may be time to revise the current definition.  In the proposed revision, the definition evolves to “Nursing informatics (NI) is a specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice. NI supports consumers, patients, nurses, and other healthcare professionals in their decision-making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology” (ANA, 2013).

This evolution fits with the concept of nurses as knowledge workers. As nurses, INSs do not simply have expertise in data and information processes.  Data capture, management, processing, retrieval, storage and the like are really our tools.  Just like any profession, the tools used do not define a person’s responsibility or contribution.  Rather, it is the outcome. In nursing, our contribution cannot be measured by how much data we capture or how we process it. It is how we use that data and what we learn from it that will move us forward.

For this reason, I think of INSs and nurses alike as being knowledge workers.   A Knowledge worker is someone who advances the overall understanding of a subject through focused analysis, design, and/or development (Tripathi, 2010). They use research skills to define problems and to identify alternatives. This process creates a culture of integrated knowledge management. As INSs, we provide information while thinking about clinical care delivery and ways to expand our knowing in nursing. We establish competencies and practice standards which we apply to nursing care delivery.  New technologies allow easier data capture and analysis. We leverage this to transform nursing practice through better sharing and management of knowledge at the point of care delivery and create a generation of new understanding about nurse’s contribution to clinical outcomes.  In short, it is what we know that matters.

Reference:

Tripathi, K. P. (2010). An Empirical Study of Managing Knowledge Workers. International journal of computer application 12:7 December 2010 Retrieved 1/25/13 from http://www.ijcaonline.org/volume12/number7/pxc3872255.pdf