Review and Revision of Nursing in the Technology World
By Karen Hunter, RN, BC, BSN
Hunter, K. (June, 2005). Review and Revision of Nursing in the Technology World. (OJNI). Vol. 9, No. 2 [Online]. Available at http://ojni.org/9_2/hunter.htm
In today’s healthcare field, end-users have more patients to care for, more data to examine and less time to document. With the addition of information technology into the healthcare setting, processes are altered with the user often “working for the system” instead of the “system working for them.” Feeling that patient documentation had become too cumbersome, a study was undertaken in August 2003 to review the documentation process in the nursing module of Meditech at Fairmont General Hospital. The study utilized interviews and surveys with end-users, a time study and a review of the set-up of dictionaries, parameters, and customer-defined screens by the Meditech consultant. Survey results were compiled, graphed and reviewed and recommendations were made to upper management for follow-up that included the formation of a documentation task force of end-users.
“Entering patient data by computer and storing it in one easily accessible location can make documentation more precise, accurate, legible, and timely. It also promotes multidisciplinary networking. Computers can facilitate data management and communication. They also reduce the time spent filing, searching for, and retrieving patient information. This frees caregivers to spend more time meeting patients’ needs.” (Mosbey) This was the intent for computerizing documentation at Fairmont General in 1997. Initial setup, however, focused on the task of building the system around current documentation practices instead of on how the practices would need to evolve to combine with the technology world. We had not done our job to make the system work for the users.
Introduction and Background:
Fairmont General Hospital is a rural hospital licensed for 250 beds and currently employees around 600 staff. Ongoing complaints from staff members regarding the length of time to document prompted this study. Clinical information systems, used correctly, can cut the time required to perform charting functions by as much as 50%, enabling staff to spend more time on direct patient care. (Wilson, Anderson) Lack of time spent with the patient was a real concern for the nursing staff, and for many nurses, the computer was the culprit.
The hospital currently uses the Meditech magic platform. Meditech is a leading software vendor in the health care informatics industry and has served over 1,900 worldwide customers for 35 years with clinical, administrative and financial modules. The modules interface on several levels, increasing interdisciplinary relations and facilitating improved patient outcomes.
Although the implementation group accepted the standard dictionary entries, several customizations to the software were added for the facility. Within the Meditech software, a user can enter a plan of care, enter documentation, print reports and view pertinent results. The system allows for automatic screening referrals, notifications, alerts and customization of the patient’s interdisciplinary plan. A documentation system should increase user satisfaction and increase documentation efficiency, accuracy, and quality. (Lising, Kennedy) It should never add to the barriers staff has to overcome in their daily planning, intervening and evaluating.
Step One: Collection of data:
Data collection was achieved via surveys, time studies, interviews and user audits. Each type of data collection is described below.
Surveys were sent on two forms. The first form was for all users of the NUR module of Meditech. It contained a total of 15 questions with three in narrative form and 12 in a scaled response. The questions reviewed personal skills, training, knowledge of the system, experience with the equipment, and basic opportunities for improvement. The number of surveys received totaled 36% of all eligible users.
The second survey was only sent to those users who worked at Fairmont General Hospital when paper documentation was in place, or those employed before the fall of 1997. The second survey contained 14 questions in narrative and scaled response formats and was used as a comparison between paper and computer charting. The number of surveys received totaled 25% of all eligible users.
The time study audits were compiled over a 12-day period and included all shifts using the Meditech User Audit. In all, 298 documentation sessions were reviewed over the 8 disciplines, including Nursing Staff, Respiratory Therapy, Physical Therapy, Dietetics, Occupational Therapy, Case Management and Speech Therapy. The routines from the NUR module that were accepted for the audit included daily tasks such as working in the plan of care, documenting in the Process Intervention routine, and documenting patient notes. Areas excluded from the audit were printing patient information, viewing information in PCI – Patient Care Inquiry, and users that were obviously logged on and walked away from the terminal, resulting in double and triple documentation times.
The time study audit was completed on users that documented on a daily basis in the Nursing module and the results were separated by the disciplines named above, the hospital unit and shift.
One-on-one and group discussions were held with various disciplines on the patient units. Interviews were on a voluntary basis with no restriction to topic. The number of interviews completed totaled 24 and included input from RN’s, LPN’s, aides, dieticians, and respiratory therapists.
During the audit process, it was determined that further data collection was needed in regards to the laptop functionality. It was found that on a user audit the end time was missing when a laptop connection would fail. These are often referred to as brownouts, “when users have their connections dropped because the access point is overwhelmed or does not effectively pass radio frequency signals. (Gillespie) Other instances when the end time may be missing was if the user exited out of Meditech using the X in the upper right-hand corner of the screen or if the battery went dead while the user was charting. Most laptops on the unit did not have the option of using the X in the top right hand corner of the screen due to the version of Meditech on the laptop. Versions of 3.22 or higher had removed this function. The user could also click on the options tab and select exit to disconnect their Meditech session. This option cannot be removed from the workstation. Instructions were posted house-wide to not use this function since it holds that session in Meditech and the user cannot access the screen until that session is deleted. Taking all of these options into consideration, missing end times on the user audit report seemed to be the only way to document when a laptop dropped a connection to the system, whether it was due to user-error or loss of connectivity.
It was also found through user interviews that the touch-pad on the laptops sometimes is accidentally pressed, minimizing the Meditech session and accessing a second session for the user. When the user accesses the second session, it disconnects the first session, losing all unsaved information.
Step Two: Compilation of data:
Survey results from both forms were compiled by department and overall. Each scaled response was graphed and comment responses listed. Nursing staff felt that the computer was superior to paper in a number of areas including creating a plan of care, meeting requirements from state and federal institutions, recalling information from a prior visit, retrieving information in a timely manner, legibility, availability of the chart, communicating to other disciplines, quality and consistency of data, and being able to view all discipline’s goals and documentation. The only area the users did not feel was improved with the computer was spending time at the patient bedside. Results were shared with end-users and upper management. Interview information was included with the survey results.
User audits were viewed by shift, by department, by discipline first separately and then as a whole. The overall average amount of time it took a user to chart was 96 minutes for an 8-hour shift and 124 minutes for a 12-hour shift.
Laptop connectivity was reviewed on the step-down unit using 2 different software programs. Laptop connections were tested in each room and assigned one of the following categories of Excellent (75-100% coverage), Good (50-75% coverage), Marginal (25-50% coverage) and Poor (0-25% coverage). On a 21-bed unit with 2 access points, 3 rooms showed poor coverage, 5 were marginal, 11 were good and only 2 were excellent.
Step Three: Analysis of data:
After the results were compiled and graphed, another list was then sent to the end-users through the IS newsletter. The users were asked to prioritize each section with a numeric value of 1 through 5, with 1 being the most important in order to discover which topics needed to be resolved first. This prioritization list, as well as recommendations, was discussed with upper management. For instance, the top five barriers to charting were
The top five suggestions for improvement included:
It was also noted that some of the users were not accessing the shortcuts in place in the system to help them in their workflow. These were reviewed as interviews took place and were also included later in training. Even though typing skills was an issue brought up by some of the staff, only 19% stated they would attend a typing class if one were offered.
Inadequate access to a computer was also noted by one unit, but a review of the hardware by Information Systems did not support that finding. Reassessment of available terminals on each unit was performed to determine the need for additional terminals. It was imperative that the users be able to document at any point in the shift. Having to wait on a terminal to be open in order to document was inconvenient as well as inefficient.
Removal of the Labor & Delivery flow sheet was already in transition during this audit process. The L&D flow sheet has since been inactivated in the system and the nurses on the L&D unit have reverted back to documenting that one piece of their charting on paper. The time it takes the RN to chart in that area has decreased by only five minutes as a result of this change.
Testing of laptop connectivity continues. The first steps taken to resolve the laptop issues included placing mice on the laptops on one unit and deactivating the touch pad. Dropped connections were monitored after this change was made. This resulted in a reduction in the number of disconnections in the user audit from 31 per month to 12 per month.
Step Four: Plan of Action/Recommendations:
Laptop connectivity became a key concern. The logic was to have the staff member at the point-of-care. When losing the connection to the network, all information that was at an unsaved status was lost and thus very frustrating for the nurses. To improve laptop connectivity the options were to place an access port in each patient room, place more access points for the laptops on each unit, order longer-lasting batteries and training of the staff on user errors. Placing an access point in each room was not financially feasible. It was decided that increasing the access points from 2 to 4 on a selected unit for testing would be the best solution. Steps were taken to test connections to the access points on the unit with the most disconnections (step-down unit selected); two more access points were added on the step-down unit prior to retesting connectivity. It is planned to have an outside source assist the IS staff with the issues of connectivity.
A documentation task force was formed to resolve issues with duplication and pertinence of data, according to priority. In order to obtain the best compliance with this task force, it was requested that the members be given an in-service day on their time period. The task force would meet under the direction of the Nurse Informaticist from the IS department. Issues to be reviewed by task force included inactivating interventions that are not used, placing a symbol, such as [*] sign, at the end of each intervention that has a customer-defined screen (CDS) attached and placing all of these interventions at the bottom of the documentation screen below the problems and goals. This team also reviewed all required fields on the CDS’s, reviewed questions on the Admission Data Base to streamline the information and make it specific to each unit. Review of the active care plans was completed and combination of duplicate questions on the CDS’s were corrected. Last, to ensure pertinent data was being offered to the end-user, the patient Kardex was reviewed.
A training plan was developed by the task force that covered three basic areas. The first request was to Human Resources to offer a basic typing class for interested employees to be held each month in combination with a basic computer skills class held by IS. The second area include placing tips and shortcuts in the IS newsletter as well as on posters which were designed by the task force members. These posters and the newsletter would be available on each unit. The third area for training involved classroom time. The use of computer-based training CD’s was selected for more detailed training. The CD’s included voice-over narration and pictures of the screens in Meditech. This would make the teaching more consistent no matter who was teaching the class.
The NUR module audit has provided insight into many areas of the system as well as time management, task prioritization, documentation process and equipment issues. Dedication to the correction of the identified problems is imperative. The resources needed to complete these tasks included creation of a task force to complete the background work on revising customer-defined screens, dictionary entries and education of end-users as well as the time and money to allow the task force users to participate. Also needed was equipment for testing and monitoring by the task force members and other facility employees as needed and last but certainly not least, upper management commitment to this process.
After completion of the study, results were published in the Information Services newsletter and presented to upper management. Volunteers were chosen to be on the task force to help redesign the system. The task force was comprised of twelve members including the Nurse Informaticist, 2 RN’s from the Step down unit, 2 RN’s from the Skilled Nursing unit, 1 nurse from OB/Labor and Delivery, 2 nurses from Medical/Surgical, 1 nurse from Intensive Care, one Behavioral Therapist and 2 nurse managers.
An operational assessment was requested from the Meditech Company to review the efficient use of the NUR module. The consultant reviewed each dictionary setup and had few recommendations. This reassured the hospital that the NUR module was being used to its capacity.
The task force decided to review each intervention with documentation screens to decrease the amount of duplication in the system. Several screens were combined and some were inactivated. Flow sheets were reviewed in several areas for need and content. Minimal changes were implemented in this area. The admission database was re-evaluated for appropriate questions. Meditech already has the ability to recall information from a previous admission assessment. In addition to that, pop-up screens were created that prompted the users to check abnormal results in each body system. This made the shift assessment and data base easier to review for staff as well as physicians. When printing, only the abnormal information displayed for review, making this a more efficient use of time when reviewing patient data.
Several areas were researched in regard to laptop connectivity. One unit was selected as the test unit with a total of 4 access points with new network cards installed.
External mice were added and the touch pad on each laptop was deactivated. A software system was also added to the laptops to improve connectivity and “hold” the session if there was a lapse in network traffic.
The task force met several times to accomplish the following:
Training of the staff members was scheduled. A computer-based training CD was created in power point and used voice-over narration to assure consistency with the educational sessions.
Time studies showed that the average amount of time needed for charting decreased by 40 minutes for an 8-hour shift and by 36 minutes for the 12-hour shift.
(See 8-hr and 12-hr graphs)
After installation of 4 new access points on the 21-bed pilot unit, no rooms displayed as poor coverage, marginal coverage was noted in the back portion of 3 rooms, 11 rooms had good coverage and 7 rooms showed excellent coverage. In addition, the new software that helps “hold” the network connection appears effective and remains under evaluation at this time. Further monitoring has proven that with this new software and new access points, connectivity between the laptops and the Meditech system nearly disappeared. Our largest obstacle now is the staff’s willingness to use the laptops after these changes have been implemented. As Donald Burt, MD. President of Bershire Faculty Services stated, “When you ‘re implementing a wireless LAN you only get one shot - if you screw it up the first time, clinicians will not be willing to try to adopt wireless technology again.” (Gillespie) Information is currently being created for distribution to all units concerning the new improvements with the laptops.
Overall, our goal was to decrease charting time and the amount of documentation for our end-users. While there is always an ongoing process of review and redesign, we feel we are on the right pathway. The participation of the end-users was of extreme importance and helped with the acceptance of the changes implemented. A post-project survey completed 2 months after implementation showed that 83% of the staff felt it took less time to chart and that duplication had been eliminated. According to survey results, 89% agreed that combining certain screens in Meditech made charting easier, and they were happier with documentation. Being able to checkmark several responses in the lookup sections for body system was approved by 100% of the end-users surveyed. In March of 2005, another survey of end-users revealed that staff have embraced the changes made in documentation.
While we continue to meet all of the standards and regulations of documentation, we eased the burden on the end-user and now have the “system working for them” instead of the user “working for the system.” Integration of technology and nursing can be accomplished in a way that everyone is satisfied. “Computers and information systems are as much a part of nursing practice today as the stethoscope. Resistance can be overcome if a collaborative effort is launched by health personnel and information technology specialists. Through cooperation and free exchange of ideas, information systems technology can facilitate major advance in improving patient care.” (Hannah, Ball, Edwards.) As we continue on our journey, combining the nursing process and information technology, we will bear in mind that it is an ever-changing and growing field. Only through working hand in hand can outcomes advance for the user as well as for the patient.
New Shift Assessment:
Combination of Pain screen and Nausea/Vomiting screens with reassessments.
Time Study Results:
8 hour shift:
12 hour shifts
Gillespie, Greg. “The Ascent of Wireless Networking”, Health Data Management (February 2004)
Mosby “Surefire Documentation“ 1999.
Lising, Maricel MS, Kennedy, Curtis MD, “A Multimethod Approach to Evaluating Critical Care Information Systems” in CIN Vol 23, Number 1 January/February 2005
Wilson, Jan RN, MS and Anderson, Mary Ann RN, MSN. “Casting electronic safety nets across care continuums.” IT Solutions, October 2004
Karen Marie Hunter, RN, BC, BSN
Ms. Hunter is a graduate of Alderson-Broaddus’ Nursing Program in 1989, she has worked at Fairmont General Hospital in West Virginia for almost 16 years. Her career started on the Cardiac Step down unit and she worked her way through the ICU unit, then to Staff Development and finally to Information Services. Ms. Hunter has been working with the Meditech system since 1996 when the hospital implemented the software from the ground up. She is certified by the American Nurses Credentialing Center in Nursing Informatics and also serves as an Instructor/Training in Basic Life Support and Advanced Cardiac Life Support at the hospital.