eHealth: Impact of Missing Documentation Noreen Frisch, PhD, RN Professor and Director School of Nursing University of Victoria

Faculty/Presenter Disclosure  Faculty: Noreen Frisch  Relationships with commercial interests:  Grants/Research Support: NONE  Speakers Bureau/Honoraria: NONE  Consulting Fees: NONE  Other: NONE

Disclosure of Commercial Support  This program has received NO financial support.  This program has received NO in-kind support.  Potential for conflict(s) of interest:  Noreen Frisch has NOT received payment or funding from any organization for this program and/or from any organization whose products are being discussed.  Organizations that hold the copyrights and intellectual property rights to any of the standardized terminologies discussed may benefit from the sales/licenses of these terminologies.

Mitigating Potential Bias  The material presented here is drawn from an extensive literature review – all information presented is publically available.  Professor Frisch is an academic presenting her own views on the topic of ‘missing documentation’ Complete reference lists are available for those interested.

We are at risk of missing data in EHRs  Documentation of the full scope of nursing and allied health contributions to health care practice  Full scope:  Naming or labeling of conditions addressed by nursing allied health professionals  i.e. each discipline’s “phenomenon of concern”  Identification of the professional interventions enacted related to these conditions  Documentation of patient of client care outcomes associated with the practice of nursing and allied health

Documenting the ‘full scope’  What is recommended by various disciplines  Nursing – use of standardized terminologies [such as the ICNP ] to record the breadth of professional nursing practice (ICN)  Dietetics – use of the Nutrition Care Process and the International Dietetics and Nutrition Terminology [IDNT]  Physical Therapy and Speech Language – use of the International Classification of Functioning, Disability and Health [ICF]

What is in our EHRs?  Medical terminologies  ICD – International Classification of Diseases  SNOMED-CT  Systematized Nomenclature of Medicine- Clinical Terms  Problem Lists  Issues that must be addressed by the care team

Interface and Reference Terminologies  Interface terminology –  Used for clinical documentation  Reference terminology –  functions as a background terminology, or one that takes terms from clinical documentation and behind the screencan map words/phases to common concepts that allow data aggregation when different terminologies are used

Literature Review  Using CINAHL as a database, a search was done to retrieve the literature on electronic documentation for Nursing, Physical Therapy Practice, Dietetics and Speech Pathology and Audiology.

For Nursing  Using [Nursing] and [standardized languages] - CINAHL retrieved 153 documents published between 1995 and present, of which 132 were directly relevant to documenting the full scope of nursing practice  Using [Nursing] and [electronic] and [documentation] CINAHL retrieved 409 articles, and 184 were directly related to use of electronic health records

Nursing and SNLs (most frequent)  40 papers on use for specific patient populations  23 on defining SNLs and teaching them  21 on implementation projects  20 on how SNLs can increase professionalism and visibility of Nursing  13 on development of SNLs  11 on use in EHRs, mapping, coding

Nursing and Electronic Documentation (most frequent)  65 papers address the scope of nursing practice/ care planning and criteria for evaluation of nursing practices  33 address specifics health conditions or disease states (pressure ulcers/pain/ speciality practice areas)  23 address nursing workflow and management issues  21 report actual integration/implementation projects  18 address education  17 on nurses’ attitudes about EHRs

Physical Therapy  Searching for [physical therapy] and [standardized language] resulted in only two papers  One related to the ICF  One related to use of NNN terminology for PT, OT and Speech Pathology  Searching for [physical therapy] and [electronic documentation] yielded 7 papers  1 on falls assessment (interdisciplinary)  1 on PT and OT in hospital EHRs  1 on electronic order entry  Others r/t home health, PT retention, rates or reasons for non-Rx with PTs, and moving to electronic documentation

Grey Literature on PT  American PT Association  Endorses the ICF as a framework for PT practice and did so in 2010  The ICF which is the International Classification of Functioning, Disability and Health is a WHO classification system that was designed to partner with ICD so that ICD and ICF could (together) provide a more comprehensive view of health

For Dietetics  Searching for [dietetics] and [standardized language] resulted in 8 papers – all related to the Nutrition Care Process (NCP) and the INDT the International Dietetics and Nutrition Terminology  Grey Literature – CANADIAN PERSPECTIVES ON THE NUTRITION CARE PROCESS AND INTERNATIONAL DIETETICS AND NUTRITION TERMINOLOGY (2010) supports the use of the NCP and the INDT

For Audiology/Speech and Hearing  Virtually no publications retrieved related to the discipline and electronic health records of standardized languages  Grey Literature  From the International Encyclopedia of Rehabilitation – language disorders follow the DSM terms

What does this literature tell us?

Summary:  Nursing and Dietetics have developed discipline-specific standardized languages to document the full scope of the professional practice  PT identifies ICF as a framework for documenting its practice and in some cases the ICF also represents speech/communication disorders.  Another set of communication disorders is represented in the DSM.

So – what did we learn?

In Nursing  In locations where there is use of discipline-specific terms, the visibility of the profession has increased  Use of discipline-specific terms have also increased the nurses’ sense of professionalism  Use of discipline-specific terms is thought to influence quality of care.

Sansoni, J & Guistini, M. (2006) More than terminology: using the ICNP to enhance nursing’s visibility in Italy, International Nursg Review 53,  In validating the ICNP for use in Italy, researchers found nursing visibility was enhanced through outcome measures as well through their study of nursing documentation through use of a common language.

Of the nursing papers on implementations  about half addressed organizational requirements for uptake of use of electronic nursing documentation  what authors report :

von Krogh, G & Naden, D (2008) A nursing- specific model of EPR of nursing documentation. J Nursg Scholarship 40(1)  Experience in Norway where nursing documentation is guided by a Health Personnel Act  Nursing modules in the EPR require process documentation – in form of a care plan and record notes in form of free text.  Presented challenges for vendors  Solutions included use of NNN for user interface and SNOMED for reference terminology and also incorporated the NMDS

Muller-Staub, M, Needham, I. Odenbreit, M., Lavin, M, and van Acherberg, T. (2008). Implementing Nursing diagnosis effectively. J Advanced Nrsg. 63(6),  Nurses have a need for education and learning about diagnostic reasoning  An interactive learning method – guided clinical reasoning -- was instrumental in establishing nursing electronic records

Noah, P. (2011) Implementing electronic documentation. Critical Care Nursing Quarterly, 34(3) 208 – 212.  Clinical ownership of the record is vital  Describes how Nursing and IT worked collaboratively to meet nursing requirements to document aspects of care (pain management)  Planned change processes are essential as is strong leadership

Klehr, J. et al. (2009) Implementation of standardized nomenclature in the EMR, International J Nursing Terminologies and Classifications 20(4) 169 – 180.  Describes with an EPIC system to enable documentation of NNN within the system  Identifies challenges with incorporating a reference terminology into a system that at that time could not be imported into the system  The organization pursued licenses with NANDA-I, NIC and NOC for care plan master files and their Epic administrators handbuilt problems, goals, or interventions that did not fit with available nursing terminology.

Of the allied health papers  Like in Nursing, a clear call for documentation of full scope of practice  Unlike Nursing, less writing about the supports and barriers to documentation n electronic records.

Take Home Messages  Need for systematic and integrated literature review  Reasonable from an academic/scholarly perspective  Need for action in the area of procurement and system design (and possible regulation)  Reasonable from a practical perspective

Conclusions  There are numerous studies that document that use of Nursing terminologies raise the visibility of the discipline and contribute to quality of care (N = 20)  EHRs in Canada and elsewhere need capacity to document the full scope of practice form nursing and allied health  Attention to the interface terminologies is critical - how do our systems use and receive nursing and allied health terms?

Conclusions  Discussions with vendors and others must include how disciplines other than medicine be represented in the record  Problems lists are not sufficient to document the scope of the practice of these professionals  Nurses and those at executive levels must be involved in procurement decisions

Are we preparing nurse leaders for information age activities in our practice settings?  Only 1/3 have any preparation at all in informatics and need for electronic documentation*  Probable similar results for other future managers/executives  *Review of curricula, west coast graduate programs : by Mary Oakes, RN, MSN; Pamela Potter, RN, DNSc; Holly Shadburne, RN, BScN; (U of Portland) and Noreen Frisch, RN, PhD, and Elizabeth Borycki, RN, PhD

Prominence of Physician documentation  In 2006, we had a call for expanding emphasis to more than physician practice in our electronic records  Hagland, M. (2006) Nursing takes center stage: hospitals are realizing that a singular focus on the needs of physicians leave nursing out in the cold. Healthcare Informatics, 23(4) 46.  Where did that call take us?

Where is Nursing in the Electronic Health Record?  Published paper in 2009  UVic: Mitchell, B, Petrovskaya, O, MmcIntyre, M and Frisch N Stud Health Technol Inform. 2009;143:202-6.Stud Health Technol Inform.

Parting words  Nursing may find support in reaching out to other health professions in efforts to include all interface terminologies in our records  Nursing must advocate for presence in EHRs beyond lists of activities  Nursing and allied health need to be proactive in procurement and implementation actions

Noreen Frisch 