Just the other day, I went on sort of a rant complaining about the excessive hype around iPad use in healthcare. I wasn’t suggesting that using iPads is a bad idea, but I was venting about the hyperbole around Apple’s latest darling.
That being said, I’ve just had a chance to be reminded why putting iPads into the hands of clinicians, or at least smart tablets, is long overdue.
Just a few days ago, a relative was in a large suburban hospital which has sunk big bucks into GE’s Centricity (one of those big gun EMRs our illustrious publisher John Lynn calls “Jabba the Hutt” products). While I sat in the room with my friend for a while, nurses came in and out a few times to take vital signs, document medication allergies and check in on my friend’s level of pain.
Do I even need to say that despite the frighteningly powerful engine sitting there rumbling within the desktops at the nurses’ stations, every one of these interactions was documented on paper?
I can only imagine a few ways that these nursing notes could get into Centricity, and none of them fill me with confidence:
* Nurses may be scanning in their documentation as they create it, then they or someone else double-checks the OCR results
* Transcriptionists could be entering data from paper notes into the Centricity system, with all the attendant potential for error this creates
* The hospital — which is otherwise extremely automated and seemingly very efficient — has just decided to create a “church and state” environment where some forms of data get into the EMR immediately and some stay on paper
Don’t get me wrong: I realize some of you reading this may already have or be developing solutions to solve just this problem. The systems I’ve seen to date, however, seem to be aimed at smaller doctors’ offices and probably wouldn’t scale to a huge tertiary care facility.
I do wish there were better point of care data collection options out there. If, in fact, tablets like the iPad are the best fit, I swear I’ll buy a few for physician friends myself. But shouldn’t hospitals and practices be doing that?
For clarity, it is good to know though, that the “Centricity” system used in the hospital is not at all the same application that is also “Centicity” in the ambulatory clinics. Centricity Enterprise is the GE Hospital EMR, Centricity Practice Solution is the product for the ambulatory offices.
That being said, it takes time and buy-in to change 50+ year old habits. While there probably is a good deal of paper documentation, I imagine much of that is being entered as data at some point outside the room, either as preference or comfort of the nurse. Absolutely not optimal in the least.
I just wanted to be clear though, John typically comments on the ambulatory solutions, of which this is not one that you reference.
It’s true that I love to talk about the Jabba the Hutt EMR systems (big, powerful, been around for a while, but a pain in the butt to get to “move”). Although, I don’t generally say which are and which aren’t. I describe the challenges of Jabba the Hutt EMR systems and let others name which ones they feel fit those criteria (there are plenty to choose from).
Chris is correct that I generally am commenting on ambulatory EMR software. I don’t know the hospital segment as well, but it wouldn’t be hard to argue that ALL (or at least almost all) of the hospital EMR systems are Jabba the Hutt EMR software right now.
Also worth noting is that the GE ambulatory EMR solution I saw at HIMSS had an iPad interface. Which I guess illustrates well your point that the small doctors offices have the iPad functionality instead of the hospitals. Most of the hospital EMR software I’ve heard has been using some sort of Citrix/RDP connection for their iPad. Less than ideal for sure.
I agree that the two step process of capturing information on paper and then entering it either manually or via Intelligent Character Recognition (ICR) – which is not that accurate for handwritten documents – is very labor intensive.
Playing devil’s advocate, entering information on an iPad keyboard is not that user friendly either, i.e., it is easy to hit the wrong key on the electronic keyboard. Which leads me to believe that information would have to be QAed also.
Coming from a document management background not a healthcare background. I am continually looking at concepts that will improve the entire process not just one step in the process. My question is do the nurses notes have to be entered into the EMR or will the capability to retrieve the images of the nurses notes in real time meet the meaningful use requirements?
nurses capture some of the most critical, trending information that is vital to a clinic or hospitals ability to produce outcomes reporting, i.e., monitoring the overall care not just of an individual patient, but patients in general. If it’s an image or document, it has -0- value.
Thanks Chris,
That is good information.
Are there QA steps put into place that ensure it’s accuracy, e.g.,what if a typo occurred or if the information is entered at the nursing station that throws the step of remeasuring what the vitals into the equations?
Are there ways to catch those errors?
Yes, to depths that are over-whelming to non-clinical people. The whole purpose of capturing the data is to not only allow for restrospective review, but provide proactive guidelines at the point of care. Those guidelines can be absed on virtually every aspect of the patient, their condition and ther history.
I have been an RN for 15 years, and I am just now getting into the EHR space, primarily because I love the technology and also because I am so tired of having to suffer through the use of substandard (for what nurses do) documentation systems. As wonderful as any of these EMR systems may be, I’m afraid you’re not going to see the paper go away anytime soon. The reason is because nurses spend much of an average shift running, metaphorically speaking, from fire to fire. We all know that the optimal situation is to document what happens as it happens. However, a typical shift will go like this (not counting all the administrative business before you even see a patient): greet patient, get vital signs, assess patient, assist patient to bathroom, answer questions, pass meds, clarify any questions that patient or RN has, run to next patient, repeat cycle, usually no fewer than 5 times. During a perfect shift, there will be no interruptions between patients, and each patient will be seen and assessed in a timely way. Believe me, this almost never happens. Then, in order to get medications administered and documented (which must be done on a timetable) on time, the other documentation is often left until there is time to sit down and chart. Even in the instance where there are terminals in every patient room, most EMRs in their current state take so long to log in and find the right screen to chart, to do so will quickly put the RN behind schedule. It is not unusual for me to go several hours into a shift before I have time to document. In the meantime, what do I do? Take very brief notes on paper to be entered into the computer later. Some facilities have the capability for vital signs to immediately and automatically register in the EMR, but few places have that, and usually they are on ICU units. Vital signs must still be entered manually in most facilities that I’ve seen. Many facilities don’t have enough terminals to document in a timely way, because it is not only the RNs who have to chart – there are physicians, physical therapists, respiratory therapists, case managers, unit secretaries and a number of others utilizing scarce resources.
So, until we start seeing a more broad adoption of newer technologies like portable tablet computers (which bring up other issues, such as infection control, but I’ll save that for another blog), I predict the paper will be with us for a while.
One more comment – as registered nurses, we are licensed professionals, and are responsible for our own documentation. It is a very important part of our job, and a key part of defending our licenses. If a question about what or how something is done, it is sometimes the only legal proof we have. So while I won’t say that typos don’t happen, I think that is not any more likely to happen if the charting was done later in the shift than if it was done right after something occurred. In fact, I could make the argument that it is less likely to happen if I have time to sit down and think than if I am rushing to chart because there’s another fire smouldering that needs my immediate attention.
Teri,
You make some interesting arguments about the time shifted charting. How about the potential issues of forgetting about something that you should document or forgetting the details of something you know you should document? I’m sure it never happens to you, but speaking hypothetically does this happen and how do you resolve it?
Another issue with charting later is the missing clinical alerts. I’ll admit to not knowing hospital nursing that well, but it seems to me that there would be some benefit to getting alerts when you’re with the patient as you’re charting their vital signs or other pertinent info, no?
I look forward to your future post on infection control and EMR. You know who do welcome guest posting on the site:-)
John, I absolutely agree with you that an ideal situation would be to be able to chart as things occur, because it is a problem to remember exactly what and when things occur. I have worked up my own little system, as have most nurses I know. And my dirty little secret is: it involves paper notes. Whereas there may not be time to log on, find the right screen, and document completely and contemporaneously, I can usually manage to jot down time and bare events as I’m running from one patient to the next, and recall the particular events later. And recording vital signs and medication administration does take priority, for just the reasons you state, because they are important for the clinical alerts. And while I may have to save the full patient assessment charting for later in the shift, I do try to do at least the most pertinent things as I go: physician phone calls, unusual findings, etc.
I don’t really know what the ultimate answer will be, but I know what we as nurses have to work with in most situations is less than optimal. We do the best we can with what we have, but in the end, IMO, it doesn’t allow us to provide the best patient care. As I see it, one of the biggest barriers to good documentation isn’t the particular system used in the hospital, it is the constant interruptions, usually of a fairly urgent nature (at least to the patient, if not to the care provider.) I am not one to tell a patient that I can’t bring a bedpan because I am busy charting, and, oops, since you just wet the bed, I better chart that too, and then I’ll bring you a bedpan. I have found we are both a lot happier if the bed wetting incident is prevented in the first place, then I don’t even have to chart it. But it may mean other things have to wait to get documented.
One hospital I know of has implemented a fairly low-tech option: the nurses where a special sash during medication administration and documentation, which basically says, “don’t bother me unless your hair’s on fire” (okay, so I exaggerate a little.) But they have realized a decrease in medication errors with just this one thing.
On a more high-tech (read 21st century) note, perhaps tablet computing will be helpful, where findings could be entered into the system immediately. I could see the possibility of voice recognition being utilized, and a quick, “pt dressing to left knee saturated with serosanguinous drainage”, with a description of wound condition as the dressing change is done, with an automatic time stamp, even if the final documentation has to be reviewed before filing. I think one of the biggest things that could be done right now is upgrade equipment with new equipment that will communicate with the EHR system already in place. Or at least with equipment that will store the data as it’s captured, even if it has to be downloaded (or heaven forbid, entered manually.) Truthfully, my research of that particular issue has led me to the discovery that most modern hospital equipment does not have the capability of communicating with most EHR systems. (Seems ironic that I can use VOIP to make free calls to the UK, but I can’t get a blood pressure machine to communicate within a hospital, doesn’t it?)
Before what I intended to be a quick response turns into a full-blown diatribe, I will go ahead and submit.
I love your blog, btw. I have learned a lot from your entries.
I really enjoyed reading this thread. It’s great when someone like Teri (who is on the front line daily) can share real experiences and pains. I have learned a lot from this post and others on this blog.
We integrate RightFax with EMR systems for hospitals & other healthcare systems. Although all of her pains cannot be “cured” with RightFax, it is generally a lifesaver for those end-users we work with.