Electronic Documentation: Implementation and Impact. Kim Bookout. Julie Dreadin. Debra Knipe. Lee Mathew. Gina Smith. Texas Woman s University

Transcription

1 Electronic Documentation 1 Running head: ELECTRONIC DOCUMENTATION Electronic Documentation: Implementation and Impact Kim Bookout Julie Dreadin Debra Knipe Lee Mathew Gina Smith Texas Woman s University HCA 5003, Summer I, Patricia Driscoll

2 Electronic Documentation 2 Electronic Documentation: Implementation and Impact We live in a time where computers are used in almost every aspect of our lives. It is not surprising that this same technology has invaded nursing documentation. Technology for computerized charting has existed for many years. Electronic documentation (ED), in some form, has been part of nursing documentation since as early as In the 1980 s, ED expanded to include medical orders, nursing interventions and patient response, and care processes (Lee, 2006). Electronic documentation has been shown to improve efficiency of data entry, increase legibility of documentation, improve access to patient information, decrease medical errors, streamline orders and improve overall delivery of patient care. It has been proposed that utilization of ED may improve patient satisfaction as nursing time at the bedside will increase. Despite its early beginnings however, electronic documentation remains conspicuously absent from several large facilities (G. Lemons, personal communication, July 8, 2008; D. Bradford, personal communication, July 3, 2008). After interviewing six local hospitals, several common themes were evident regarding implementation of electronic documentation and the impact on nursing staff. Literature Review Many studies show that successful implementation of the electronic medical record in an organization requires proper planning (Johnson & Martin, 1996; Lee, 2006; Turpin, 2005; Bush &

3 Electronic Documentation 3 Ebel, 1996). Even small facilities find the change to an electronic medical record (EMR) potentially overwhelming. Methods to insure a successful implementation should be thoroughly planned. Brumleve and Thede (2006) state that the preimplementation is the most important phase of the process. If issues are not recognized prior to implementation, technology may be blamed for documentation. It is important that each department of the organization is involved. This gives the facility leadership the ability to identify potential risk prior to the change. The ability to address misconceptions head-on can be beneficial to the successful implementation for the organization. A common theme in much of the literature addressing successful implementation of the EMR was a systemized method. It can be assumed that a systemized method for implementation may improve nursing satisfaction throughout the process as well. Bush and Ebel (1996) cited several methods to ensure successful implementation. Methods include sufficient training of staff, sufficient time allowed between introduction of the functions and the actual rollout, and allowing time for changes to be made. Staff that will be utilizing the product should be included on the project team to allow for preview of the content and flow of data. A consistent communication should be in place throughout the planning and implementation stage. Tools should be developed to measure the pre-implementation and post-implementation documentation data. A paucity of literature exists regarding electronic documentation s impact on nursing time at the bedside. Although

4 Electronic Documentation 4 many articles addressed documentation time and efficiency, none correlated decreased time for documentation with increased time spent in direct patient care activities. Bush and Ebel (1996) report an initial increase in documentation of admission assessments (60-90 minutes) but within two weeks of implementation, documentation times decreased to minutes which was similar to times prior to institution of the EMR. Methods and Procedure Telephone interviews were conducted with nursing leadership in six local facilities including: Medical Center of Lewisville, Parkland Health and Hospital System, Arlington Memorial Hospital, Baylor Irving Medical Center, Baylor Health Care System, and Presbyterian Hospital of Dallas (Texas Health Resource). Questions asked were related to processes employed while evaluating EMR systems, preparations made by the facility for implementation, when implementation occurred, support systems for ongoing training and upgrades, and improvements observed following implementation such as, patient satisfaction related to nursing, and nursing staff s perception of increased time at the bedside (Appendix). Results Interview data from the six facilities yielded many similarities. However, facilities have marked variation in sophistication regarding data tracking. For example, four facilities acknowledged tracking staff satisfaction although little data were collected related specifically to satisfaction

5 Electronic Documentation 5 with electronic documentation. Question 1 Each facility was asked to discuss how decisions were made regarding the purchase of an electronic documentation program. One of the six facilities reported the system was chosen per a corporate mandate. All of the other facilities selected leadership from multiple departments. Although it is assumed that each facility chose a program for ease of use, only one facility specified this in the interview. Only one of six facilities mentioned cost of the program as a factor considered in their selection process. Question 2 Facilities were then asked to discuss specific considerations given to the project prior to implementation. Each facility mentioned large numbers of meetings with multidisciplinary groups. Groups were tasked with determining appropriateness of the system within individual departments. One facility discussed the involvement of managers in the development of screens specific to their departments. At Baylor Health Care System (BHCS), D. Bradford (personal communication, July 3, 2008) discussed the necessity of an organization to consider its current processes basic to advanced. For example, charting should begin at the point of care versus beginning an hour prior to shift change. In addition, protocols or best practice documents should be in place for nursing so that transitioning to the computerized care planning is not new information. Dr. Bradford further iterates that organizations must have consistent practice

6 Electronic Documentation 6 between facilities including best practice guidelines and documentation guidelines. In other words, having a wonderful electronic medical record is not going to excuse poor medical or nursing decision making. Question 3 Each facility was then asked to describe specific preparations that were made prior to the go live date. Unanimously, the interviewees describe many hours of classroom time as well as hands-on practice for staff and physicians. Nurses at BHCS were asked to describe mental algorithms followed in patient care. Educators in the organization gave the nursing staff scenarios (video and written). The nurses were then required to document or chart on paper and then chart using the computer system. One of the six facilities interviewed delineated the role of the manager in preparations for implementation. They identified the need for the manager to assess potential barriers to implementation. Once the barriers were identified the information technology staff was able to predict areas for modification or reinforcement. Other items for consideration were identified as, electrical power, access points, data ports and switches, construction (preparation of walls for mounting, creating new space, etc.), contractual arrangements for hardware when large volumes are necessary. Question 4 Program implementation dates ranged in the six facilities from 1993 through However, not all facilities had implemented their electronic documentation program in all areas of the organization. Parkland Health and Hospital system (G.

7 Electronic Documentation 7 Lemons, personal communication, July 8, 2008) implemented a system in the clinics and laboratory in At present, the facility is looking toward a system-wide launch of a new ED program (Epic) in September, Arlington Memorial Hospital (D. Brannagan, personal communication, July 9, 2008) launched Meditech in 1996 but is currently in the process of converting their system to Epic. The Baylor Irving Hospital had a DOS system in place for computer charting prior to the merger of the Irving facility with BHCS. Now, as part of BHCS, the facility will convert its program to be consistent with the entire organization (J. Eclipse, personal communication, July 9, 2008). Three of the six interviewed facilities implemented one program but found it necessary to convert or upgrade to a new system. Another incidental finding was that 1/3 of the facilities had worked for several years toward implementation of programs before switching completely to a different program. This was not only costly in terms of finance but also in terms on human resource. Question 5 When facilities were questioned regarding necessary support systems for launch and ongoing support, each identified support teams that were in place 24 hours per day and seven days per week. Another strategy employed by 1/3 of the facilities was concomitant paper charting. This was carried out through the initial phase of implementation only. Presbyterian Hospital of Dallas trained and identified super users for their system (M. B. Mitchell, personal communication, July 7, 2008) that

8 Electronic Documentation 8 theoretically were in place on each unit for each shift. The super users were the designated resource for each unit as they implemented the program. Anecdotally, managers reported working many hours of overtime during the launch of the ED program (M. B. Mitchell, personal communication, June 26, 2008). Question 6 Challenges following implementation of each facility s were varied. Parkland s system identified that although additional training is necessary for staff, there is not enough information technology staff to provide ongoing training. Arlington Memorial Hospital reports that as the facility has launched new components to their program, they have had increased complaints from nursing and physicians. D. Naylor, MD (personal communication, July 10, 2008), Chief of Pediatrics at Medical Center of Lewisville reports difficulty in accessing records such as vital sign trends, bilirubin trends and weight changes when seeing patients in the newborn nursery. Additional challenges reported by facilities included the need for upgrading an antiquated system, nurses skipping areas in the assessment and continued requirements for paper documentation. One facility reported the need to remove charting from the bedside in order to increase bedside care. Question 7 Lastly, facilities were asked to describe noted improvements since implementation of ED programs. One half of the facilities reported their programs met JCAHO requirements of documentation. Each facility reported increased access to patient information

9 Electronic Documentation 9 for all caregivers within the organization. Each facility reported decreased medical errors although only one facility provided statistical evaluation. Arlington Memorial Hospital identified that older physicians were more interested in learning the new system than their younger counterparts. They also had audits to identify weaknesses so that leadership teams could make rapid adjustments to the system. One half of the facilities reported that while nursing time at the bedside had decreased rather than increased following implementation of the ED systems. Only one of the six facilities provided specific information related to nursing satisfaction (M.B. Mitchell, personal communication, July 6, 2008). A web-based survey was sent to all registered nurses with 171 nurses responding. Questions were asked related to utilization of the system as well as their perception of impact on patient care. Most respondents were employees at the facility less than five years and rated their computer expertise as good. Items were rated using a Likert 5- point scale. Questions with the highest ratings were related to ease of use of the Epic system. Questions with the lowest ratings were related to patient care and outcomes. This is also true with Medical Center of Lewisville, Parkland Health & Hospital System, and Baylor Irving. Discussion There has been little evaluation of nursing time at the bedside in the literature related to implementation of ED by healthcare organizations. Although one would like to surmise that using the EMR would improve the nurse s ability to spend greater

10 Electronic Documentation 10 time in direct patient care activities, current results are inconclusive. In fact, results of this project revealed just the opposite. Five of the six facilities reported a decrease in nursing time at the bedside with one of the facilities stating the need to remove documentation from the bedside in order to improve direct patient care. Facilities that appeared to have the most successful implementation and satisfaction were those who had launched a complete system at one time instead of portions of the system sequentially. Implementation of ED requires an ongoing commitment from all levels of staff in order to be successful. Conclusion Electronic documentation has had an impact in healthcare organizations. And although nursing time at the bedside has not increased, other aspects of care processes have improved. As facilities begin or continue implementation of EMRs, organizational leaders must include multidisciplinary teams in the development of critical programs that meet the needs of individual units. D. Bradford, vice-president for Nursing Professional Development at BHCS (personal communication, July 3, 2008) emphasizes the need for technology to support practice instead of taking over practice. The EMR will be as successful as the protocols, guidelines and best practices already integrated into the organization. When this occurred there was a high level of satisfaction of the nurses and staff with computerized documentation. Further exploration is warranted regarding the development of guidelines for implementation and utilization in

11 Electronic Documentation 11 order to improve overall outcomes related to process improvement and finally patient care. References Bush, A. & Ebel, C. (1996). Testing an electronic documentation system. Nursing Management, 27(7), Brumleve, R. & Thede, L. (2006). The benefits of a preimplementation phase in electronic medical record implementation project. Computer Informatic Nursing, 24(5), Johnson, D. & Martin, K. (1996). Preparing for electronic documentation. Nursing Management, 27(7), Lee, T. (2006). Nurses perceptions of their documentation experiences in a computerized nursing care planning system. Journal of Clinical Nursing, 15, Turpin, P. (2005). Transitioning from paper to computerized documentation. Gastroenterology Nursing, 6(7),

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13 Appendix Electronic Documentation 13

14 Electronic Documentation 14 Interview Questionnaire 1. How did the facility decide which electronic medical records system to purchase and implement? 2. What information was considered prior to the implementation of the computerized program? 3. What preparations were made prior to going live with the chosen program (i.e. training, hardware, etc)? 4. When was the program implemented? 5. What support systems were put in to place for the initial and ongoing issues? 6. What challenges have occurred since implementation of the system? 7. What improvements have been apparent since implementation of the system?