Toolbox
Questions – Answers - References
ReF # / KEYWORDS / Questions / Answer / Reviewed by(Taskforce Member) / Data or Evidence? / Number of Responses / Reference/Source / Date /
1 / Functionality
Policy
Clinical practice
Efficiency
Optimization
Copy forward / What issues should be considered related to ‘copy forward’? / Copy forward may be used very carefully. Clear policies covering this use should be available.
When making this decision, the following should be considered:
Stakeholders in the decision: CNO’s, Practice Councils, Risk Management, Legal department.
Review of software to determine functionality – clinical IT and clinicians
Is ‘copy forward’ present in any application currently?
What data is copied forward – and what is not allowed to be brought forward?
Is there a standard in place?
How is validation accomplished? How the caregiver is assured that the data is not simply copied forward, but is reviewed prior to storing the data? / Melissa Barthold
Lisa Bove
Jim Cato
Brenda Kulhanek / Evidence and data-
Survey Results:
(date) / http://journal.ahima.org/2008/06/04/an-appropriate-use-of-copy-forward-with-a-caveat/
Discussion on CARING list / April, 2009
7 / Hardware
Mobile
Portable devices
Criteria for selection
Storage
Power
Hallway
Fire codes
State regulation
Fire Regulation
Design
Ergonomics / What are current practices related to use and storage of mobile documentation devices such as rolling computer carts?
Are mobile carts (COW’s, WOW,s, etc.) allowed in the hallway? / To be considered:
Instruct staff to move mobile devices from hallways into alcove or nurses’ station to comply with fire/state regulations.
For design/redesign, consider creating elevated floor with outer perimeter docking or alcoves that includes power/network drops.
Consider wireless.
How are devices flexed in response to staff or patient census. What area is available for parking the devices to maintain power?
Place outlets/network drops at an ergonomic height. / Brenda Kulhanek
Lisa Bove
Melissa Barthold
Portia Towns / Data / CARING list July 2009
3 / Physiological data
Monitors
Data validation
Interface data capture
Policy
Practice
Optimization / Should physiologic data imported from monitors be validated before data is it stored in the EMR? / Any physiological data imported from monitors into an electronic documentation system must be approved or validated by the nurse prior to its storage in the EMR.
Issues: Validating that data is correct coming across an interface
Ensures clinician evaluation of the data prior to storage and provides the ability to observe trending or to correct technical issues, such as lead artifact or monitor/interface issue. / Brenda Kulhanek
Lisa Bove
Melissa Barthold
Portia Towns / Data-
CARING list / Discussion on CARING list
Further questions for investigation
2 / Electronic Signature
HIPPA
Documentation
Policy
Practice / How is the electronic signature defined? / Electronic signature is legal in all 50 States and the security standards of electronic signatures are addressed in the security and privacy provision of the Health Insurance Portability and Accountability Act (HIPAA).
It can be an electronic sound, symbol, or process associated with a record.
It can be an automatic signature added by a system when an entry is saved by the user or it can be an intentional act of signing an electronic document.
It is an electronic indicator added to the electronic medical record, including flowsheets, orders, notes, etc. that indicates signature of the licensed provider. It may not require additional separate action (such as re-entry of a password) – it may be as simple as the act of saving the data entered is the ‘signature’.
HIPAA-covered entities that use electronic signatures for transactions must adhere to U.S. Department of Health and Human Services electronic signature standards. The software program must provide:
· Nonrepudiation - assurance that the signer cannot deny signing the document in the future,
· User authentication - verification of the signer's identity at the time the signature was generated, and
· Message integrity - certainty that the document has not been altered since it was signed. / Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
Portia Towns / Portability and Accountability Act (HIPAA) / Portability and Accountability Act (HIPAA).
http://www.hhs.gov/ocr/privacy/hipaa/administrative/statute/hipaastatutepdf.pdf.
4 / Documentation
Standards
Policy
Practice
Requirements
Design
Minimum data sets / What should be considered when designing electronic documentation? / When making this decision, the following should be considered:
· Build documentation that reflects standard practice and regulatory requirements. Examples: Minimum data sets from nursing organizations, Joint Commission, CMS and the Bureau of Vital Statistics.
· Who is going to view/utilize the data? Only collect data that is used by the care team or regulatory requirements.
· Purpose of documentation:
o Communication among caregivers
o Support of billing
o Potential for research
o Longitudinal record of patient’s health status and treatments
· Support documentation of assessments and treatments that reflect the standard of patient care as established by local, state and national regulations
· Guides staff to document the “right things” by preventing documentation of the “wrong things” through proper design
· Guides staff to document the “right things” by preventing documentation of the “wrong things” through proper design
Suggestions:
· Documentation Categories:
o Assessments
o Interventions
o Biometric data
o Summary/Evaluation data
o Progress Notes
o Care Plans
o Demographic data
o Patient education
o Communication to members of the patient care team
o Communication between members of the patient care team
· Format of documentation
o Easily viewed
o Supports efficient documentation
o Ability to obtain data for reporting (limited free-text fields)
o Consider all disciplines- documentation needs and access needs / Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
5 / What type of format should be used to indicate errors or changed documentation?
“Error explanations– changes – how much should be in strikethrough format? Or should it be in that format?” / Is this vendor specific? Can it be configured to one standard?
CHIT standard?
HIM standard?
Risk Management?
24 / What policies should be addressed prior to electronic documentation design/implementation?
6 / What are the best devices and device configurations that support nursing workflow? / When making this decision, the following should be considered:
Do you support point of care (real-time at the patient’s side) charting?
What applications are currently in use and what are planned?
If you are using electronic medication records with bar coding, do you need a place to store individual medications?
8 / What is the best practice for maintaining the power supply on mobile devices?
9 / How is the appropriate number of documentation devices determined?
10 / Charting
Real time
Point of care
Documentation
Devices / How is ‘timeliness of charting’ defined?” How is this affected by the constraints of documentation technology? / When making this decision, the following should be considered:
Was there a ‘timeliness of documentation’ policy before automation? Any such policy needs to be reexamined or created prior to implementation of electronic documentation.
Has timeliness been defined in other applications such as medication administration or ancillary charting?
What type of device (WOW, tablet, compute in the room, desktop, etc.) does the user have access to?
Generally, prior to automation, ‘timeliness of charting’ was defined by the expectation that the clinician would complete documentation prior to the end of their shift. With automation, the focus has moved to ‘real-time’, although ‘real-time’ can vary based on the type of device that a clinician uses. Late charting has been defined anywhere from 30 minutes (often based on medication administration policies) to 4 hours (batch charting twice a shift).
However defined, the policy needs to match practice. / Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
11 / Are ‘default’ answers in forms permitted? How is the scope of default answers determined? / When making this decision, the following should be considered:
Do you allow defaults on paper forms or in other applications?
12 / Melissa / What processes are used to document during a computer downtime?
13 / Trish / What data entry recovery and backfill processes are used after a computer downtime? What are the decision making processes to determine what data gathered during a downtime is backfilled into the computer system? What timeframes are used to determine what data is backfilled into the system and when the backfill must be completed? / Part of the project implementation should include a multidisciplinary focus group to determine downtime processes based on different types of downtime (ie Network, EMR clinical repository, ancillary systems that are interfaced etc). The main focus in determining what information is entered after a downtime should be centered around ensuring that risk to the patient is minimized after a downtime. It is important to consider:
1. The type of information. Information such as allergies, height and weight for Pharmacy orders and medication information should always be back entered since this is information required for the care of the patient.
2. Who uses the information? Is the information only used by one ancillary department or is it reviewed by numerous providers to make clinical decicions?
3. How long has the system been down? A downtime which impacts a change in care providers (ie over a shift change) may be handled differently than one that does not. Often a downtime that is 4 hours or less may be handled differently than one which extends longer than 4 hours.
4. Shat is the impact to it not being available in the EMR? If the patient is readmitted, will the information be valuable to have in the EMR (ie home medications, allergies, history etc)? Is the information related to the medication administration process? This high risk process may need to be handled differently since it involves a higher risk to the patient.
5. What risk exists for the patient if the information is not entered?
6. Is there a mechanism to denote a downtime occurred in the EMR so providers reviewing the information know to reference the paper chart
14 / Lisa / What is current practice for communication of downtimes to clinical areas?
15 / What is current practice for communication of system-related changes, enhancements or downtimes?
16 / Does charting-by-exception support best practice? Is it legally defensible? / Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove / "Ladies & gentlemen of the jury, I present... the nursing documentation".Full Text Available (includes abstract); Austin S; Nursing, 2006 Jan; 36 (1): 56-64 (journal article - case study, CEU, exam questions) ISSN: 0360-4039 PMID: 16395021 CINAHL AN: 2009089387
17 / What is current practice for enhancement request prioritization? How are clinical enhancement requests reviewed? Does the review of clinical enhancement requests include an assessment of the clnical impact of the changes?
18 / What documentation by non-licensed staff is permitted in the EMR? What is current practice related to RN co-signature of documentation entered by non-licensed staff? Is the practice or policy enforced through technology or policy alone?
19 / Jim Cato / What is current practice related to managing clinical students’ access to clinical documentation systems? / CARING
20 / How is the future state included in the planning and execution of current implementations or enhancements? How are technology decisions analyzed that may negatively impact future enhancements/building? How are decisions made when an urgent need is addressed in a future enhancement that is not an organizational priority? What is the current best practice window for future technology planning?
21 / What is current practice for training staff. What is the current practice for training and utilizing SuperUsers? How are SuperUsers best utilized as a resource?
22 / Portia / What QA is necessary for electronic systems?
Who should do QA?
23 / How is standardization of practice analyzed, implemented and measured?
24 / What is the current state of EHR use in mental health?
25 / How are ancillary departments trained to use the EHR?
26 / What is the best practice for use of computer protective equipment such as keyboard covers, and computer cleaning for computers used in patient care areas
27 / Mark / What is the best way to plan and manage ongoing change between IT and the clinical areas?
28 / How is emergency access to the HIS available? / For staff members, such as those from Organ Procurement provided 2/47?
Identify staff who may be using the system.
Preferred: Create logins for all agency staff members.
Create one ID for each agency and require a member to call the help desk, where the date/time/name of the staff member is recorded prior to issuing a password. The password expires in a defined time frame. / Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove / data / 8-14-09
29 / how you manage sound on computers in your hospital setting. We are having discussions about enabling sound on select devices where possible for nursing and patient education (products like Elsevier, etc). How do your hospitals handle staff and patient education? Do you have sound-enabled devices at certain locations? If so, how is your patient education material approved? Do you have sound at devices in nursing stations / CARING list / 8-18-09
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