Clinical documentation is widely known to be a time-consuming task. Much of that documenting rests on the shoulders of nurses, who use health information technology to help juggle their many roles: caring for patients, helping to maximize performance in the midst of changing reimbursement models, achieving regulatory compliance, promoting better outcomes and increasing patient satisfaction.
Unfortunately, nurses often feel as though the tools designed to help capture and share information are part of the problem. A major issue is lack of standardization. Some healthcare organizations attempt to meet everyone’s needs by creating specific resources to accommodate individual clinicians or departments. That lack of consistency paired with excess requirements leads to variability in care. While everyone agrees that capturing, documenting and disseminating clinical data is essential, it’s also clear that there’s a need to improve how it’s done, including the processes and tools involved.
“Nursing documentation as a whole is frequently enhanced and expanded upon, and flowsheet-related content is no exception,” explains Jessica Campbell, DNP, RN, Clinical Informaticist, LogicStream Health. “Often, flowsheet rows are customized, causing unnecessary variation and duplication. As a result, multiple versions of a single flowsheet row can send users down different pathways. Unfortunately, these duplications persist within the EHR where they go on to deliver outdated and often competing guidance long after evidence-based best practices have been revised.”
Driving fragmented care
“Traditional workflows used by nurses and then the rest of the care team often contribute to fragmented care,” says Tiffany McCauley, MSN, RN, Clinical Executive, Elsevier. “This can happen due to the siloed-nature of healthcare settings, such as differences between the ambulatory and acute care settings, or varying approaches used by various specialties, but we also see fragmented care within a single department. The reason is that each discipline, or interprofessional teammate, has their own set of tools they use, which live in the EHR but never get merged together.”
For example, if a physical therapist (PT) has just been at the bedside visiting a patient, how does the nurse tap into the information coming out of that visit? Can the nurse easily find out what the PT thinks about how the patient is doing and the care plan they have put in place? Are those insights, which are essential to ensure patient safety, brought to life within the nursing workflow? Or does the nurse have to search the EHR to find it? Unfortunately, it’s often the latter. If the nurse isn’t aware that the PT goal for the patient is walking 50 feet that day with a standby assist, the nurse might have the patient walk more – or less – and do so unassisted.
Consider how discrepancies like the PT example are multiplied throughout the day for every patient, because insights from each member of the care team all exist in different parts of the EHR. They’re all guided by different workflows, some of which may be driven by outdated evidence. It paints a compelling case of the urgent need for optimization.
“Care fragmentation increases patient healthcare costs while diminishing the quality of care,” says McCauley. “In this environment, important health issues are not properly addressed, patient health outcomes are at risk, and there is an increased likelihood of unnecessary or potentially harmful health services.”
Documentation optimization is even more critical when caring for patients who endure one or more chronic conditions and are particularly at risk of fragmented care. That’s because caring for these patients typically involves multiple participants who each provide specialized knowledge, skills and services. What needs to be done to fix this problem and provide coordinated care? One answer is to optimize processes and systems to reduce variation and ensure clinicians are using up-to-date, evidence-based guidance.
Building in evidence-based guidance
“The volume of available medical knowledge is doubling every few months as new guidelines are released and standards are updated,” says McCauley. “It’s unrealistic for any care team to keep up with all the relevant, evidence-based information that impacts patient care. That’s why the integration of evidence-based medicine into clinical workflows is essential. Its application at the bedside drives ongoing improvements in clinical decision-making and, ultimately, overall patient outcomes.”
So how do hospitals streamline their systems to remove variation and consistently deliver current, evidence-based guidance? First, it helps to understand how the content inside the EHR tends to evolve, and why.
“Hospital systems make multiple changes in their EHRs every day,” says Campbell. “Sometimes those modifications are based on the unique needs of a specialty area, but other requests for changes may be rooted in how a team in a particular nursing department prefers to interact with the system. These changes are made with the intent of increasing efficiency, but the overall impact often is just the opposite.”
Using data-driven insights
To optimize nursing documentation, health systems are using clinical process improvement solutions that provide data-driven insights into the extent of duplication, frequency of changes and comparison with best practices to determine which guidance has the most clinical value. Armed with that information, hospitals can make necessary adjustments to their EHR.
In addition to speeding up the documentation process, the removal of unnecessary flowsheet duplication helps the entire clinical team ensure continuity of care when the patient is transitioned to another part of the health system. This is especially important when caring for patients with complex health needs.
“Technology solutions are now available to assess the clinician workflows and understand how care is being provided. By evaluating workflows alongside outcomes, health systems can understand where the evidence-based best practices are being followed and where they can be implemented,” said Campbell. “More importantly, once those workflows are implemented, measuring and managing those workflows as the evidence changes are ways we can have a significant positive impact on patient outcomes.”
Clinicians are hungry for change. Reducing the documentation burden on nurses lets them focus on the more rewarding aspects of their job. A recent study revealed that 85 percent of clinicians agree that coordinated, collaborative, interprofessional practice increases their job satisfaction.
“If people don’t understand how to use the evidence-based content and apply it to their day-to-day work, then it’s not solving the issue of fragmented systems,” explains McCauley. “It’s important to achieve a balance by implementing the right content and technology while focusing on the clinical team’s perspective and working from there to achieve the interprofessional collaboration required under emerging quality-based care models.”
About Jessica Campbell, DNP, RN
Jessica Campbell, DNP, RN, is a Clinical Informaticist at LogicStream Health. Campbell is an informaticist and registered nurse focused on quality of care, improving documentation standards and clinical process improvement. As a registered nurse she provides care in the perioperative and critical care specialties. Campbell earned her Bachelor of Science in Nursing from the University of Wisconsin-Eau Claire and her Doctor of Nursing Practice in Nursing Informatics from the University of Minnesota-Twin Cities.
About Tiffany McCauley, MSN, RN
Tiffany McCauley, MSN, RN serves as a Nursing Executive with Elsevier Clinical Solutions. In this role she collaborates with health care systems, academic centers and physician practices to reduce variation in care, standardizing practice and improving patient outcomes through the application of evidence-based decisions at the point of care. Prior to joining Elsevier McCauley lead the development of nursing and patient education programs at a number of leading community-based health care organizations. Her focus has been on improving staff engagement and the patient experience by leading change initiatives related to standardizing clinical knowledge and practice while effectively engaging patients in their care across care settings. McCauley believes this is a key component in improving the healthcare experience for patients.