EHR documentation burden is not a brand new concern, however the issue got here to a head throughout the COVID-19 pandemic as nurses and different clinicians had been beneath rising strain to supply care to increasingly more sufferers throughout virus surges.
“That is one thing that, ever since EHRs have been about, there have at all times been usability points. Do we actually have to be documenting that? How can we doc issues that actually do have to be put into the digital well being file?” Stephanie Hoelscher, DNP, affiliate professor and informatics nurse specialist on the Texas Tech College Well being Sciences Heart, advised MobiHealthNews.
Hoelscher and Serena Bumpus, DNP, regional senior director of medical surveillance at Ascension, needed to take a deep dive into what hospitals had been doing in Texas throughout surges, and determine how they may higher deal with crises sooner or later.
However the objective of the Texas pilot examine goes past infectious ailments like COVID-19. They took an “all-hazards method,” so hospitals may extra shortly swap to disaster documentation requirements within the occasion of different disasters or well being threats.
“Disasters can occur at any time exterior of a pandemic,” Bumpus mentioned. “When you concentrate on hurricanes, tornadoes, every other sort of catastrophe … We have to have a look at this as one thing in a much bigger image, as a result of that is a lot greater than only a world pandemic. And so that actually was what launched our examine and the work we’re doing proper now.”
Some documentation requirements cannot be reduce, like these which might be regulatory necessities or are wanted for affected person security, like treatment adherence. However many hospitals applied adjustments to preliminary screenings, admission assessments and discharge processes.
Their upcoming nationwide examine will proceed the analysis and work to outline what a surge is, which might differ based mostly on state and protection space. The objective is to determine what’s working for almost all of suppliers, thus permitting hospitals to duplicate their concepts and alter them as crucial.
It additionally highlights the significance of together with nurses and different clinicians who’re closely utilizing the EHR when contemplating adjustments.
“To me, ensuring that you’ve introduced nurses into the dialog is paramount,” Hoelscher mentioned. “In case you have two non-clinician informaticists taking a look at one another and saying, ‘What ought to we do? What do you wish to do?’ That needs to be your cue to cease. In the event you two do not know, then that you must get anyone concerned that does know.”
On the identical time, EHR documentation adjustments can typically trigger friction, even when these updates are backed by proof. Making adjustments throughout a high-stress time like a COVID-19 surge will also be tough, as a result of the EHR could all of the sudden look loads much less acquainted.
“As nurses, the digital well being file is so deeply embedded into the work that we do. We create this cadence on how we doc,” Bumpus mentioned. “I’ve at all times appeared on the EHR sort of like a grocery retailer. So you realize the place the bread is, you realize the place the milk is. And you may go proper there, and you will get in, and you will get out. However in the event you go to a model new grocery retailer, you have to go searching for all of that stuff.”
The HIMSS22 session “Lowering Nursing Documentation Burden in a Time of Disaster” will happen on Tuesday, March 15, between 3:00 p.m. and 4:00 p.m. in Orange County Conference Heart W330A.