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.