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Dr. Sam 6/18/12

June 18, 2012 News 5 Comments

A Key Missing Element of EHRs

Nurses play a key — if not crucial — role in successful hospital EHR implementations.

  • They are the first people that frustrated physicians complain to and often have to deal with borderline or actual abusive commentary or language emanating from an angry physician.
  • They are often the initial super-users who can show physicians how to navigate through specified workflows that they may not have absorbed during EHR training (if they attended training sessions at all).
  • They often have to enter orders or deal with verbal orders given by a physician who cannot (or does not want to) enter orders by Computerized Provider Order Entry processes (CPOE – please note use of the term “Provider” and not “Physician,” which is the true appropriate use of the acronym CPOE.)
  • They are often the first users in the go-live schedules for clinical documentation.

In spite of their key role in patient care, by tradition (in both paper and electronic worlds), their clinical notes are almost universally unread by physicians. In spite of being the caregivers who spend far more time at the bedside than any other clinicians, their notes are either ignored, or at best casually reviewed by physicians.

As a result, both the paper and electronic environments are often replete with documentation contradictions with inaccurate information entered by either the physician or the nurse, or with information that conflicts with patient status. After cataract surgery, a nurse might enter “Pupils Equally Round and Reactive to Light and Accommodation (PERRLA) when one pupil is pharmacologically dilated or constricted, or a physician might document “Patient fully ambulatory and stable” when the patient is in fact unable to get out of bed or has had fluctuating vital signs. The number of possible conflicting entries is both unlimited and endemic.

This is where standard vocabulary becomes as important as accurate clinical observations. An EHR functionality that has been lacking since the early years of clinical information system design has been the ability to cross reference nursing and physician clinical documentation notes and to generate alerts when contradictions are present. This is not only of essential importance to patient care, but to reducing vulnerability to medical liability.

Sam Bierstock, MD, BSEE is the founder of Champions in Healthcare, a widely-published author, and a popular featured speaker on issues at the forefront of the healthcare industry.

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Currently there are "5 comments" on this Article:

  1. Dr. Sam – have you seen any vendor even attempt this level of documentation cross-checking? It seems like a daunting task but not completely unlike medication interactions and reactions where it is handled by a single vendor with a single module like FDB, Medispan and Multum, then integrated to the architecture. Settling on the base terminologies is critical otherwise one is building on sand so to speak. If each vendor develops these rules or if it is left to the clients to write rules, it will be a nightmare and would certainly result in more calls for deep FDA oversight.

  2. The correlation problem is bad enough within a single clinical record entry, not to mention between different ones by different people. The problem is, to find every contradiction between, say, the H&P and the ROS or physical exam you either have to require pure template-driven data entry for everything with no narrative free text at all (with the well-known unreadability problem), or an incredibly sophisticated real-time text mining system well beyond any current capabilities.

  3. Good point Robert. There is software out there that will mine text-based data entry for discrete data points, so it’s probably accomplishable even with free text entry, but still a daunting task as you rightly point out.

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