After reading Mr Reynolds' letter concerning electronic documentation information systems (EDIS), or “computerized charting,” I felt compelled to respond. Our facility had a very successful implementation of an EDIS approximately 14 months ago. We went from a total paper system with no tracking board to electronic physician/nurse documentation, medication services, and tracking board with our initial implementation. Very shortly we will begin electronic charge by documentation as well as order entry to complete our EDIS.
In response to Mr. Reynolds' bullet points:
•An EDIS cannot teach medicine. The assessment skills of an ED nurse with 2 years of experience can hardly be compared with those of a nurse with 30 years' experience. However, a robust EDIS can remind, assist, and improve an inexperienced nurse's documentation as his or her assessment skills improve. An EDIS should never be expected to take the place of the experienced nurse mentoring the inexperienced nurse.
•An EDIS cannot be likened to any of the current technology used to actually care for patients. Technology enhances and improves patient care; an EDIS enhances and improves documentation.
•An EDIS cannot take time away from or depersonalize patients, although a nurse can make that choice. Granted, the length of stay for patients in our department initially increased as the staff became proficient at documentation, but it returned to time zero within 6 months. The time spent with our patients has not suffered, as is obvious by our patient satisfaction scores. In the Press Ganey All Hospital Database, we ranked in the 99th percentile in the last quarter of 2006.
•Our system automatically time-stamps all entries, but just as with a paper chart, each nurse must enter the actual time of the assessment or procedure. If charting appears to be in real time and was not, the “constant lie” was created by the nurse's inadequate charting, not by the EDIS.
•An EDIS does not require that you check off any boxes. Many options are available to create an honest, thorough chart. Dishonest documentation can occur in a paper chart just as easily if not more so. If a nurse falsifies documentation, it is because the nurse made that choice; the system did not. Our EDIS keeps all changes in documentation in the background for administrative viewing as a safeguard.
•Charge by documentation is a huge marketing point for all electronic documentation systems. Our system can recognize approved charges, thus decreasing the time spent by coders to glean this information. Although the system offers increased coding capacity, our coders continue to thoroughly review each document to reconcile charges prior to billing. Billing for services is a sometimes unsavory but very necessary part of health care that is required for us to continue caring for patients.
We have found that our EDIS has improved every aspect of our documentation. The system reminds each of us to document what we had often thought of as insignificant information but what now have become Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements. The system has built-in safeguards for medication prescribing and dispensing. We are able to assess and document a patient's suicide risk, fall risk, and skin condition in a matter of minutes without trying to locate 3 different forms. The medication and allergy history of a patient automatically appears in his or her chart for confirmation with every visit. The details of all patient visits are available with one click of a mouse. Having a pharmacist check all nonacute medication orders has been a struggle for emergency departments across the United States. We were able to implement a process for this requirement that is documented in our EDIS. Medication reconciliation has been another difficult process for many departments. Our system automatically prints discharge instructions, prescriptions, and a medication reconciliation form that is sent home with each patient. In addition, a visit summary and medication reconciliation form is automatically faxed to the primary care physician upon discharge. During our last JCAHO survey in August 2006, we were one of few hospitals in the United States that did not receive a single Medication Services Requirement for Improvement, partially because of our EDIS.
All of this is not to say that our ED staff has not worked very hard to make our EDIS work. We have become a leader in our health care system because of our success with electronic documentation, and our staff and physicians are very proud of this distinction. Everyone in our department would tell you that their documentation takes more time than with paper, but they would also tell you that they are able to document the excellent care that they give each and every one of our patients. I am sure that Mr Reynolds and his co-workers are experienced ED nurses, but I wonder which EDIS they are using and what unrealistic expectations they have been led to believe.
Clinical Coordinator, Emergency Services, Providence Newberg Medical Center, Newberg, Ore
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