Effken, J. & Weaver, C. (JuLY, 2016). Spring Cleaning—The Informatics Version. Online Journal of Nursing Informatics (OJNI), 20(2). Available at http://www.himss.org/ojni
A few days ago, the first author saw the movie, “Hello, My Name is Doris,” in which Doris’ home is packed to the rafters with “treasures” she and her deceased mother have collected over the years—most of it (like a single ski) rescued from being discarded “just in case” it might someday be needed. The movie, which is both funny and sad at times, reminded the author of just how important it is to look at what we collect and save (at home and at work) “just in case.” Most of the time, the “just in case” event never occurs.
The “House” of Nursing Documentation Needs Cleaning
Unfortunately, nursing documentation in electronic health records (EHR) has become a house with data “treasures” piled to the rafters—much of it “just in case” it might be needed. In a study of nursing documentation at Bon Secours Health System, CNO Patricia Sengstack (personal communication, 2016) found that just completing the nursing admission assessment required that nurses access 14 different screens and complete 153 “required fields,” using a total of 539 key clicks to do so. Based on this study, Sengstack estimated that only 25% of the nursing data in the EHR was useful to nurses. In fact, most of the nurses’ documentation was never read by another nurse, let alone another health professional. Bon Secours is now engaged in serious house cleaning to see what data can be eliminated, not only in the admission assessment, but in other areas. Sadly, the burden of nursing documentation is not restricted to acute care settings. Nursing assessments are even more time-consuming in home health, where Nancy Staggers (personal communication, 2016) reports that they routinely consume two hours of a nurse’s day.
Essential Clinical Information: Lost in the Clutter
Because the clinical documentation in today’s EHRs is so highly fragmented (not only by separate checklists and screens), but also by role (physicians, nurses, social workers, etc.), too often it is difficult to discover the patient’s actual story (Varpio, Rashotte, Day, King, Kuziemsky, & Parush, 2015). A patient may be asked to repeat information she told one professional to many others, leaving her wondering whether health professionals ever talk to each other and if they even bothered to enter her answers in the EHR. When the first author’s husband’s sought treatment for a kidney stone in an emergency department (ED), a nurse documented his vital signs, pain level, etc. and took a urine sample. The next three persons he encountered asked some of the same questions until the frustrated author reminded them that her husband was in severe pain and they should be able to get their answers from the EHR. During all the questioning and recording, the urine sample was lost—and had to be collected again before definitive treatment could be initiated!
Are We Nearing a Tipping Point?
We have been working in informatics for over 30 years. What happened to our dreams of an EHR that supported nursing practice and improved patient outcomes? Perhaps we should have foreseen the challenges because the EHR evolved out of a business model in which problems are black and white (and mathematically computable)—and has never been a particularly good fit for the complex, fuzzy problems of health care. However, the EHR is ideal for collecting a variety of data, providing the necessary documentation for reimbursement, and serving as a warehouse for various standards. Consequently, today’s EHR has been coopted by administrative requirements and so today it serves as the “backbone” supporting institutional priorities (regulatory and legal requirements, quality improvement initiatives, reimbursement, accreditation standards, and evidence-based practice standards) (de Reuter, Liaschenko, and Angus, 2015). Although each of these priorities clearly has some value, taken together they comprise much of the clutter that describes today’s documentation systems.
Physicians were the first to voice their dissatisfaction with the growing burden of electronic documentation. Nurses have been more tolerant and quieter until recently; but as additional documentation requirements are imposed, it is likely we may experience a rebellion similar to that of physicians. Staggers, Elias, Hunt, Makar, & Alexander (2015) reported that an informal 2014 survey of over 13,000 nurses showed that over 90% were dissatisfied with their EHRs, citing disruptions to communication, workflow, and productivity. Millennials are actually leaving nursing because they view current documentation systems as antiquated and archaic.
To Bring Order out of Chaos, Start by Cleaning House
Years ago, the first author worked with a Connecticut hospital to streamline their nursing documentation and, at the same time, make the initial assessment an interdisciplinary process. The CNO had discovered that, over the years, each time an accreditation team made a recommendation, another form or documentation procedure was added to documentation requirements until the whole process became overwhelming. The CNO elected to clean house and design a new documentation process and forms, starting with a clean slate and an interdisciplinary team.
Similar house cleaning activities are beginning to occur elsewhere. Jane Englebright (personal communication, 2016) and her colleagues at HCA began to tackle their nursing documentation overload by first developing an ideal workflow and how data should flow, which then led to their developing workflow and data flow maps. Using the new maps, they developed data models that served as generic, or “technical,” specifications for programmers. In addition, the team looked at physician order sets and deleted non-value orders that specified nursing activities that nurses already were carrying out. The team used Virginia Saba’s Clinical Care Classification (CCC) system to build multidisciplinary care plans, finding that the body system framework of the CCC communicated more effectively to multiple disciplines than other frameworks. Although HCA had two different vendors’ EHRs in place, the generic specifications worked equally well for both, thus achieving the same documentation goals in two separate information systems. Dr. Jane Englebright, HOA’s Chief Nursing Executive is convinced that nurses should use similar generic specifications to define their innovations because these can then be implemented within any vendor system.
Toward a Repository for Sharing Best Informatics Practices
In 2016, nurses remain “data-rich, information-poor . . . because each health care organization implements an EHR system without the ability to leverage lessons learned from organizations that have gone before them or access a “best practice” central repository that holds examples as data sets complete with clinical terms mapped to standardized terminologies such as clinical LOINC and SNOMED-CT” (O’Brien, Weaver, Settergren, Hook, & Ivory, 2015, p. 334).
As nurses, and particularly as nurse informaticists, we need to get on with our spring cleaning of nursing documentation—and we need to share our solutions so that we don’t keep reinventing the wheel. If we are to reap the potential rewards of electronic documentation, such as generating nursing data from which we can change practice to improve patient safety and quality outcomes, we need to throw away what is not needed and concentrate instead on what has real value—and we need to share with others in the field how we accomplished this (a “Hints from Heloise”, if you will, for nurses informaticists and leaders), but, in this case evidence-based help).
As co-chairs of a group working on the Big Data project begun at the University of Minnesota, our challenge is to create a national repository for best practices in nursing informatics that are generic, i.e., vendor neutral. These evidence-based practices will have been demonstrated to improve practice and/or patient outcomes in at least one setting and may range from decision support tools to generic templates for assessments, or even templates for coding in LOINC or SnoMED (Note that Susan Matney and Judy Warren have already begun that effort for wound care, and their exemplar is freely available on the HL7 website under resources). We welcome your feedback and ideas, as well as news of how your own spring cleaning is progressing. We also welcome volunteers to help us meet our challenge. You may contact us at firstname.lastname@example.org or email@example.com.
De Ruiter, H-P, Liaschenko, J., & Angus, J. (2015). Problems with the electronic health record. Nursing Philosophy, 17, 49-58. http://dx.doi.org/10.1111/nup.12112
O’Brien, A., Weaver, C., Settergren, T., Hook, M. L., & Ivory, C. (2015). EHR documentation: The hype and the hope for improving nursing satisfaction and quality outcomes. Nursing Administration Quarterly, 39(4), 333-339. http://dx.doi.org/10.1097/NAQ.0000000000000132
Staggers, N., Elias, B. L., Hunt, J. R., Makar, E., & Alexander, G. L. (2015). Nursing-centric technology and usability: A call to action. Computers, Informatics, Nursing: CIN, 33(8), 325-332. http://dx.doi.org/10.1097/cin.0000000000000180
Varpio, L., Rashotte, J., Day, K., King, J., Kuziemsky, C., & Parush, A. (2015). The EHR and building the patient’s story: A qualitative investigation of how EHR use obstructs a vital clinical activity. International Journal of Medical Informatics, 84, 1019-1028. http://dx.doi.org/10.1016/j.ijmedinf.2015.09.004