Paper-based Documentation Research Articles

Implementation of the Nutrition Care Process and International Dietetics and Nutrition Terminology in a Single-Center Hemodialysis Unit: Comparing Paper vs Electronic Records

There is little doubt surrounding the benefits of the Nutrition Care Process and International Dietetics and Nutrition Terminology (IDNT) to dietetics practice; however, evidence to support the most efficient method of incorporating these into practice is lacking. The main objective of our study was to compare the efficiency and effectiveness of an electronic and a manual paper-based system for capturing the Nutrition Care Process and IDNT in a single in-center hemodialysis unit. A cohort of 56 adult patients receiving maintenance hemodialysis were followed for 12 months. During the first 6 months, patients received the usual standard care, with documentation via a manual paper-based system. During the following 6-month period (Months 7 to 12), nutrition care was documented by an electronic system. Workload efficiency, number of IDNT codes used related to nutrition-related diagnoses, interventions, monitoring and evaluation using IDNT, nutritional status using the scored Patient-Generated Subjective Global Assessment Tool of Quality of Life were the main outcome measures. Compared with paper-based documentation of nutrition care, our study demonstrated that an electronic system improved the efficiency of total time spent by the dietitian by 13 minutes per consultation. There were also a greater number of nutrition-related diagnoses resolved using the electronic system compared with the paper-based documentation (P<0.001). In conclusion, the implementation of an electronic system compared with a paper-based system in a population receiving hemodialysis resulted in significant improvements in the efficiency of nutrition care and effectiveness related to patient outcomes.

Tablet-based cardiac arrest documentation: A pilot study

AimConventional paper-based resuscitation transcripts are notoriously inaccurate, often lacking the precision that is necessary for recording a fast-paced resuscitation. The aim of this study was to evaluate whether a tablet computer-based application could improve upon conventional practices for resuscitation documentation. MethodsNurses used either the conventional paper code sheet or a tablet application during simulated resuscitation events. Recorded events were compared to a gold standard record generated from video recordings of the simulations and a CPR-sensing defibrillator/monitor. Events compared included defibrillations, medication deliveries, and other interventions. ResultsDuring the study period, 199 unique interventions were observed in the gold standard record. Of these, 102 occurred during simulations recorded by the tablet application, 78 by the paper code sheet, and 19 during scenarios captured simultaneously by both documentation methods These occurred over 18 simulated resuscitation scenarios, in which 9 nurses participated. The tablet application had a mean sensitivity of 88.0% for all interventions, compared to 67.9% for the paper code sheet (P=0.001). The median time discrepancy was 3s for the tablet, and 77s for the paper code sheet when compared to the gold standard (P<0.001). ConclusionsSimilar to prior studies, we found that conventional paper-based documentation practices are inaccurate, often misreporting intervention delivery times or missing their delivery entirely. However, our study also demonstrated that a tablet-based documentation method may represent a means to substantially improve resuscitation documentation quality, which could have implications for resuscitation quality improvement and research.

Description and comparison of documentation of nursing assessment between paper-based and electronic systems in Australian aged care homes

PurposeTo describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment. MethodsThis was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated. ResultsVarying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms). ConclusionsElectronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.

AMIA board of directors response to Simborg perspective

AMIA board of directors response to Simborg perspective

OHP-027 Educational Model For IT Systems

BackgroundAn electronic documentation management system had been implemented, replacing and uniting three previously paper-based documentation systems. 130 users located on 6 different locations needed to be educated in the new...

Enabling flexible integration of healthcare information using the entity-attribute-value storage model.

BackgroundFor an optimal care of patients in home healthcare, it is essential to exchange healthcare-related information with other stakeholders. Unfortunately, paper-based documentation procedures as well as the heterogeneity between information systems inhibit a well-regulated communication. Therefore, a digital patient care record is introduced to establish the foundation for integrating healthcare-related information.MethodsFor the digital patient care record, suitable integration techniques are required that store data in a compact way and offer flexibility as well as robustness. For this purpose, a generic storage structure based on the entity-attribute-value (EAV) model is introduced. This storage structure fulfills the stated requirements and incoming information can be stored directly without any loss of data.Evaluation Results and DiscussionsFirst performance tests regarding the query response time are given in this paper. The tests measured the connection time, the query execution time, and the time for traversing the result set. The time for executing the query is lowest. The time for traversing the results strongly depends on the number of documents. A concept comparison to other integration techniques is also presented.ConclusionsThis approach offers flexibility concerning different standard types and the evolution in healthcare knowledge and processes. It also allows for highly sparse data to be stored in a compact way. The underlying database structure is presented, the import process for extracting incoming reports is described and the export process for generating new outgoing standardized reports is briefly illustrated.

PTU-231 Bowel preparation for inpatient colonoscopy: an audit of quality and outcomes

IntroductionIt is well recognised that inpatient colonoscopy is more problematic than outpatient colonoscopy, with poorer quality of bowel preparation1 and reduced rates of successful completion of the procedure among inpatients.2...

Web-Based Electronic Health Records Improve Data Completeness and Reduce Medical Discrepancies in Employee Vaccination Programs

A Web-based electronic health record (EHR) system was compared with traditional paper-based documentation and vaccination tracking during the 2009 H1N1 influenza pandemic. In a cohort of 8,411 healthcare network employees, EHRs improved completeness of self-reported contraindication data and reduced medical discrepancies. Vaccination program quality and accuracy are enhanced by EHRs.

Color-Coding and Human Factors Engineering to Improve Patient Safety Characteristics of Paper-Based Emergency Department Clinical Documentation

Investigators studied an emergency department (ED) physical chart system and identified inconsistent, small font labeling; a single-color scheme; and an absence of human factors engineering (HFE) cues. A case study and description of the methodology with which surrogate measures of chart-related patient safety were studied and subsequently used to reduce latent hazards are presented. Medical records present a challenge to patient safety in EDs. Application of HFE can improve specific aspects of existing medical chart organization systems as they pertain to patient safety in acute care environments. During 10 random audits over 5 consecutive days (573 data points), 56 (9.8%) chart binders (range 0.0-23%) were found to be either misplaced or improperly positioned relative to other chart binders; 12 (21%) were in the critical care area. HFE principles were applied to develop an experimental chart binder system with alternating color-based chart groupings, simple and prominent identifiers, and embedded visual cues. Post-intervention audits revealed significant reductions in chart binder location problems overall (p < 0.01), for Urgent Care A and B pods (6.4% to 1.2%; p < 0.05), Fast Track C pod (19.3% to 0.0%; p < 0.05) and Behavioral/Substance Abuse D pod (15.7% to 0.0%; p < 0.05) areas of the ED. The critical care room area did not display an improvement (11.4% to 13.2%; p = 0.40). Application of HFE methods may aid the development, assessment, and modification of acute care clinical environments through evidence-based design methodologies and contribute to safe patient care delivery.

Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care

Electronic health records are expected to improve the quality of care provided to hospitalized patients. For nurses, use of electronic documentation sources becomes highly relevant because this is where they obtain the majority of necessary patient information. An integrative review of the literature examined the relationship between electronic nursing documentation and the quality of care provided to hospitalized patients. Donabedian's quality framework was used to organize empirical literature for review. To date, the use of electronic nursing documentation to improve patient outcomes remains unclear. Future research should investigate the day-to-day interactions between nurses and electronic nursing documentation for the provision of quality care to hospitalized patients. The majority of U.S. hospital care units currently use paper-based nursing documentation to exchange patient information for quality care. However, by 2014, all U.S. hospitals are expected to use electronic nursing documentation on patient care units, with the anticipated benefit of improved quality. However, the extent to which electronic nursing documentation improves the quality of care to hospitalized patients remains unknown, in part due to the lack of effective comparisons with paper-based nursing documentation.

The changes in caregivers’ perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home

Purpose To date few studies have compared nursing home caregivers’ perceptions about the quality of information and benefits of nursing documentation in paper and electronic formats. With the increased interest in the use of information technology in nursing homes, it is important to obtain information on the benefits of newer approaches to nursing documentation so as to inform investment, organisational and care service decisions in the aged care sector. This study aims to investigate caregivers’ perceptions about the quality of information and benefits of nursing documentation before and after the introduction of an electronic documentation system in a nursing home. Methods A self-administered questionnaire survey was conducted three months before, and then six, 18 and 31 months after the introduction of an electronic documentation system. Further evidence was obtained through informal discussions with caregivers. Results Scores for questionnaire responses showed that the benefits of the electronic documentation system were perceived by the caregivers as provision of more accurate, legible and complete information, and reduction of repetition in data entry, with consequential managerial benefits. However, caregivers’ perceptions of relevance and reliability of information, and of their communication and decision-making abilities were perceived to be similar either using an electronic or a paper-based documentation system. Improvement in some perceptions about the quality of information and benefits of nursing documentation was evident in the measurement conducted six months after the introduction of the electronic system, but were not maintained 18 or 31 months later. Conclusions The electronic documentation system was perceived to perform better than the paper-based system in some aspects, with subsequent benefits to management of aged care services. In other areas, perceptions of additional benefits from the electronic documentation system were not maintained. In a number of attributes, there were similar perceptions on the two types of systems.

Is paper-based documentation in an emergency medical service adequate for retrospective scientific analysis? An evaluation of a physician-run service

ObjectiveTo investigate if paper-based documentation in the authors' emergency medical service (EMS) satisfies scientific requirements.MethodsFrom 1 July 2007 to 28 February 2008, data from all paper-based protocols of a physician-run...

Real estate e-conveyancing: vision and risks

More then 150 years had passed since English solicitors expressed their vision of a land registration system in which land transactions are quickly and smoothly registered at the same manner in which securities are transferred in the stock exchange. This vision led to the development of the Torrens system and to its expansion in various sides of the globe. Yet the reality of land conveyancing was far from accomplishing this old vision. The process of registration in many jurisdictions suffered from bureaucratic delays and was, and in many jurisdictions still is, based on analogical paper-based documentation system. Though many systems had gone through a computerization process, it dealt with the presentation of manually entered information rather than direct and automatic registration of digital applications. It was only the last decades of the twentieth century that brought to reality the idea of real estate e-conveyancing according to which a land transaction should be automatically processed and registered from the stage of the application to the stage of final registration. A few countries made a great deal of effort to develop such a system but yet there is a way ahead until its conclusive implementation. Israel land registry is going to launch an e-registration project as well. The article analyzes the vision of e-conveyancing and compares it to the current progress of the e-conveyancing projects around the world. It shows that the safe identification of parties, documents and signatures is the major problem of all the newly developed e-conveyancing systems and that this problem is the main obstacle that prevents a full scale implementation of e-conveyancing.

Development of electronic medical record charting for hospital-based transfusion and apheresis medicine services: Early adoption perspectives

Background: Electronic medical records (EMRs) provide universal access to health care information across multidisciplinary lines. In pathology departments, transfusion and apheresis medicine services (TAMS) involved in direct patient care activities produce data and documentation that typically do not enter the EMR. Taking advantage of our institution′s initiative for implementation of a paperless medical record, our TAMS division set out to develop an electronic charting (e-charting) strategy within the EMR. Methods: A focus group of our hospital′s transfusion committee consisting of transfusion medicine specialists, pathologists, residents, nurses, hemapheresis specialists, and information technologists was constituted and charged with the project. The group met periodically to implement e-charting TAMS workflow and produced electronic documents within the EMR (Cerner Millenium) for various service line functions. Results: The interdisciplinary working group developed and implemented electronic versions of various paper-based clinical documentation used by these services. All electronic notes collectively gather and reside within a unique Transfusion Medicine Folder tab in the EMR, available to staff with access to patient charts. E-charting eliminated illegible handwritten notes, resulted in more consistent clinical documentation among staff, and provided greater real-time review/access of hemotherapy practices. No major impediments to workflow or inefficiencies have been encountered. However, minor updates and corrections to documents as well as select work re-designs were required for optimal use of e-charting by these services. Conclusion: Documentation of pathology subspecialty activities such as TAMS can be successfully incorporated into the EMR. E-charting by staff enhances communication and helps promote standardized documentation of patient care within and across service lines. Well-constructed electronic documents in the EMR may also enhance data mining, quality improvement, and biovigilance monitoring activities.

Concept and implementation of a single source information system in nuclear medicine for myocardial scintigraphy (SPECT-CT data)

Data for clinical documentation and medical research are usually managed in separate systems. We developed, implemented and assessed a documentation system for myocardial scintigraphy (SPECT/CT-data) in order to integrate clinical and research documentation. This paper presents concept, implementation and evaluation of this single source system including methods to improve data quality by plausibility checks. We analyzed the documentation process for myocardial scintigraphy, especially for collecting medical history, symptoms and medication as well as stress and rest injection protocols. Corresponding electronic forms were implemented in our hospital information system (HIS) including plausibility checks to support correctness and completeness of data entry. Research data can be extracted from routine data by dedicated HIS reports. A single source system based on HIS-electronic documentation merges clinical and scientific documentation and thus avoids multiple documentation. Within nine months 495 patients were documented with our system by 8 physicians and 6 radiographers (466 medical history protocols, 466 stress and 414 rest injection protocols). Documentation consists of 295 attributes, three quarters are conditional items. Data quality improved substantially compared to previous paper-based documentation. A single source system to collect routine and research data for myocardial scintigraphy is feasible in a real-world setting and can generate high-quality data through online plausibility checks.

Software Engineering: A fundamental Approach to Automate and Interface Medical Electronic Systems with Computers in Healthcare Systems

The cost for application software and propriatry standards (i.e. data structure and formats) required for storing clinicaldatasets from electronic device cause the use of time-consuming paper-based documentation and/or the transfer ofelectronic lab records manually to the PC database systems in Mother-Offspring Malaria Study (MOMS) LaboratoryUnit located in Morogoro Regional Hospital, Tanzania. We have explored the ability to extract laboratory results fromHaematology analyzer machine for easy management, access and storage. The methodology and tools used during thestudy includes; site survey and hands-on practice for requirement engineering, visual basic 6.0 for interface design andMicrosoft Access for relational database design. The study has developed a model “ CO mpose- TRA ansmit- CO nvent-CO mpose” convention (acronym COTRACOCO) to implements an open serial port interface that required only a driverclass to execute the labs outputs for storage in database with at run-time with less programming knowledge. The studydemonstrated that the COTRACOCO convention presented is general and may promote a new paradigm for establishingthe robust serial port communication systems for any digital device.

Evacuation support system for improved medical documentation and information flow in the field

Purpose Documentation of medical treatment and observation of patients during evacuation from the point of injury to definitive treatment is important both for optimizing patient treatment and managing the evacuation process. The current practice in military medical field documentation uses paper forms and voice communication. There are many shortcomings associated with this approach, especially with respect to information capture and sharing processes. Current research addresses the use of new technology for civilian ambulance-to-hospital communication. The research work presented in this article addresses information capture and sharing in extreme military conditions by evaluating a targeted computerized information system called EvacSys during a military exercise in northern Norway in December 2003. Methods and materials EvacSys was designed and implemented in close cooperation with military medical personnel in both Norway and the USA. The system was evaluated and compared to the traditional paper-based documentation method during a military exercise. The on-site evaluation was conducted in a military medical platoon in the Norwegian Armed Forces, using questionnaires, semi-structured interviews, observation and video recording to capture the users’ system acceptance. Results A prototype software system running on a commercial off-the-shelf hardware platform was successfully developed. The evaluation of this system shows that the usability of digital information capturing and sharing are perceived to be at least as good as the traditional paper-based method. The medics found the new digital method to be more viable than the old one. No technical problems were encountered. Conclusions Our research shows that it is feasible to utilize digital information systems for medical documentation in extreme outdoor environments. The usability concern is of utmost importance, and more research should be put into the design and alignment with existing workflow. Successful digitalization of information at the point of care will provide accurate and timely information for the management of resources during disaster response.

A notary archive model for secure preservation and distribution of electrically signed patient documents

The healthcare industry is moving from paper-based documentation into the digital era. Electronic health records (EHR) are playing a major role in this development. Electronic health records will not only to be shared among a growing number of healthcare providers but they have also to be archived over long periods of time. The required life cycle depends of national regulations, but typically the preservation time of patient data varies between 20 and 100 years. Availability, integrity, confidentiality and non-repudiation of stored data over these lengthy preservation periods needs to be fully proven, both to preclude loss and also ensure the ability to read and understand content is maintained. This document describes a co-operative trusted notary archive (TNA) which receives granular health data from different EHR-systems, stores data together with associated meta-information for long periods and distributes granular EHR-data objects. TNA communicates with EHR-systems and external users via archive request and distribution messages. TNA can store objects in XML-format and prove the non-repudiation and integrity of stored data with the help of event records, Time-stamps and archive e-signatures.

Structured data entry for narrative data in a broad specialty: patient history and physical examination in pediatrics

BackgroundWhereas an electronic medical record (EMR) system can partly address the limitations, of paper-based documentation, such as fragmentation of patient data, physical paper records missing and poor legibility, structured data entry (SDE, i.e. data entry based on selection of predefined medical concepts) is essential for uniformity of data, easier reporting, decision support, quality assessment, and patient-oriented clinical research. The aim of this project was to explore whether a previously developed generic (i.e. content independent) SDE application to support the structured documentation of narrative data (called OpenSDE) can be used to model data obtained at history taking and physical examination of a broad specialty.MethodsOpenSDE was customized for the broad domain of general pediatrics: medical concepts and its descriptors from history taking and physical examination were modeled into a tree structure.ResultsAn EMR system allowing structured recording (OpenSDE) of pediatric narrative data was developed. Patient history is described by 20 main concepts and physical examination by 11. In total, the thesaurus consists of about 1800 items, used in 8648 nodes in the tree with a maximum depth of 9 levels. Patient history contained 6312 nodes, and physical examination 2336. User-defined entry forms can be composed according to individual needs, without affecting the underlying data representation. The content of the tree can be adjusted easily and sharing records among different disciplines is possible. Data that are relevant in more than one context can be accessed from multiple branches of the tree without duplication or ambiguity of data entry via "shortcuts".ConclusionAn expandable EMR system with structured data entry (OpenSDE) for pediatrics was developed, allowing structured documentation of patient history and physical examination. For further evaluation in other environments, the tree structure for general pediatrics is available at the Erasmus MC Web site (in Dutch, translation into English in progress) [1]. The generic OpenSDE application is available at the OpenSDE Web site [2].

Cognitive analysis of physicians and nurses cooperation in the medication ordering and administration process

The objective of this study was to analyse physician–nurse cooperation in the medication ordering and administration process from a cognitive point of view. In this paper, we compared two work organizations characterized by: (1) a synchronous cooperation engendered by common doctor–nurse medical rounds and (2) an asynchronous situation characterized by split physician's and nurse's rounds. Both organizations worked with paper-based documentation systems. We relied on a cooperation cognitive architecture model and used specific methods from cognitive ergonomics to analyse physicians’ and nurses’ activity, communications and cooperation. The analysis of doctor–nurse dialogues during the medical rounds demonstrated that in the synchronous situation, the nurses actively participated in the medication ordering process. Such dialogues supported the elaboration of shared knowledge in the form of a common frame of reference (COFOR) which both actors rely on to control the entire medication process, and more precisely the coordination of their actions. Document analysis showed that the orders were far from exhaustively documented. However, self-confrontation interviews with the nurses demonstrated that, except for a small number of ill-documented orders, they were able to accurately retrieve the physician's complete intended orders. In this work organization, the nurse was able to control the medication administration process at a high level, because she understood the highest level of strategic control of the medication ordering carried out by the physician. In the asynchronous situation, the results were reversed. The nurses no longer participated in the decision making phase of the medication process. Doctor–nurse communications were rare, and their shared knowledge about the patient was weakened. Although written orders proved to be better documented, the nurses suffered from a lack of knowledge on the patient's medical case and the particular context of the medical decision making when confronted with incomplete or ambiguous orders. In this work organization, the nurse would find herself restrained to low level process control and confined in a reactive, instead of anticipative, management mode. This latter work organization is very similar to the CPOE situation we observed in previous studies, where the coordination of physicians’ and nurses’ actions was delegated to the system. We suggest that it is essential to take these organizational and cognitive aspects into account when (re-)designing CPOE applications.