Four Years Later: Examining Nurse Perceptions of Electronic Documentation Over Time.

OBJECTIVE: To examine changes in registered nurse (RN) perceptions of electronic documentation over a 4-year period. BACKGROUND: The investigators previously reported differences in RN perceptions prior to and 1 year after adoption of a comprehensive electronic health record (EHR). METHODS: Investigators repeated the study 4 years after adoption, using the Nurses' Perceptions of Electronic Documentation tool and interviews with a subset of RNs. RESULTS: Nurses scored higher on ease of use domain and lower on concern about the EHR domain and showed no difference on the impacts of the EHR domain. Interviews revealed that 4 years later, some aspects of documentation were easier; the tool was comprehensive, but not without risk, and nurses remained ambivalent about the EHR. CONCLUSIONS: Use of EHR technology impacts nursing work. It is important to understand how nurses' perceptions change over time. This study gives nursing leaders insight into adoption and acceptance of an EHR.

"Languaging" tacit judgment in formal postgraduate assessment: the documentation of ad hoc and summative entrustment decisions.

While subjective judgment is recognized by the health professions education literature as important to assessment, it remains difficult to carve out a formally recognized role in assessment practices for personal experiences, gestalts, and gut feelings. Assessment tends to rely on documentary artefacts-like the forms, standards, and policies brought in under competency-based medical education, for example-to support accountability and fairness. But judgment is often tacit in nature and can be more challenging to surface in explicit (and particularly written) form. What is needed is a nuanced approach to the incorporation of judgment in assessment such that it is neither in danger of being suppressed by an overly rigorous insistence on documentation nor uncritically sanctioned by the defense that it resides in a black box and that we must simply trust the expertise of assessors. The concept of entrustment represents an attempt to effect such a balance within current competency frameworks by surfacing judgments about the degree of supervision learners need to care safely for patients. While there is relatively little published data about its implementation as yet, one readily manifest variation in the uptake of entrustment relates to the distinction between ad hoc and summative forms. The ways in which these forms are languaged, together with their intended purposes and guidelines for their use, point to directions for more focused empirical inquiry that can inform current and future uptake of entrustment in competency-based medical education and the responsible and meaningful inclusion of judgment in assessment more generally.

Electronic Health Record Workstation Single Sign-on: A Quantification of Time Liberated for Nurses to Care for Patients.

OBJECTIVE: The aim of this study was to quantify the impact of electronic health record (EHR) workstation single sign-on (SSO) for nurses. BACKGROUND: SSO was implemented in 19 hospitals for expedited EHR access. METHODS: Login durations before and after SSO implementation were compared, and the financial value of nursing time liberated from keyboard was estimated. Stratified analyses show time liberated and financial value by staffing level and system size. RESULTS: First-of-shift login was reduced by 5.3 seconds (15.3%) and reconnect duration was reduced by 20.4 seconds (69.9%). SSO liberated 27,962.4 hours of nursing time from keyboard login per year across 19 facilities, and 1,471.7 hours/year/facility, valued at $52,112/facility and $990,128 for 19 hospitals. Time value ranges from $201,835 per year for a 5-hospital system with 300 nurses per facility to $672,790 per year for a 10-facility system with 500 nurses per hospital. CONCLUSIONS: Nurses gained substantial time liberated from EHR keyboard by SSO for patient care, having significant financial value for the organization.

Envisioning an artificial intelligence documentation assistant for future primary care consultations: A co-design study with general practitioners.

OBJECTIVE: The study sought to understand the potential roles of a future artificial intelligence (AI) documentation assistant in primary care consultations and to identify implications for doctors, patients, healthcare system, and technology design from the perspective of general practitioners. MATERIALS AND METHODS: Co-design workshops with general practitioners were conducted. The workshops focused on (1) understanding the current consultation context and identifying existing problems, (2) ideating future solutions to these problems, and (3) discussing future roles for AI in primary care. The workshop activities included affinity diagramming, brainwriting, and video prototyping methods. The workshops were audio-recorded and transcribed verbatim. Inductive thematic analysis of the transcripts of conversations was performed. RESULTS: Two researchers facilitated 3 co-design workshops with 16 general practitioners. Three main themes emerged: professional autonomy, human-AI collaboration, and new models of care. Major implications identified within these themes included (1) concerns with medico-legal aspects arising from constant recording and accessibility of full consultation records, (2) future consultations taking place out of the exam rooms in a distributed system involving empowered patients, (3) human conversation and empathy remaining the core tasks of doctors in any future AI-enabled consultations, and (4) questioning the current focus of AI initiatives on improved efficiency as opposed to patient care. CONCLUSIONS: AI documentation assistants will likely to be integral to the future primary care consultations. However, these technologies will still need to be supervised by a human until strong evidence for reliable autonomous performance is available. Therefore, different human-AI collaboration models will need to be designed and evaluated to ensure patient safety, quality of care, doctor safety, and doctor autonomy.

Aspects of Technology That Influence Athletic Trainers' Current Patient Care Documentation Strategies in the Secondary School.

CONTEXT: Previous research on athletic trainers' (ATs) documentation practices in the secondary school setting has focused on users of 1 electronic medical record (EMR) platform. These studies have identified that ATs use multiple platforms for documentation, including paper, even when an EMR is available. OBJECTIVE: To examine the documentation practices of ATs who use various forms of patient care documentation, including paper, EMRs, or both. DESIGN: Qualitative study. SETTING: Individual telephone interviews. PATIENTS OR OTHER PARTICIPANTS: Twenty ATs participated in this study: 12 women and 8 men who averaged 38 ± 14 years of age, 15 ± 13 years of clinical experience, and 11 ± 11 years of employment at their current secondary school. DATA COLLECTION AND ANALYSIS: Semistructured telephone interviews were conducted to gain insight into ATs' documentation practices. Three researchers and 2 auditors inductively coded the transcripts using a consensual qualitative research process that consisted of 4 rounds of consensus coding and determination of data saturation. Trustworthiness was addressed with member checking, multiple-analyst triangulation, and peer review. RESULTS: The ATs' documentation practices were largely influenced by technology, organized in 3 themes. Participants' current documentation strategies included the use of both paper and EMRs, as they found different benefits to using each platform. Oftentimes documentation practices were shaped by technological challenges, including unreliable networks, software design problems, and the lack of a streamlined approach. Lastly, participants identified future strategies for improving documentation, including the need for better EMR options and streamlining their individual documentation behaviors. CONCLUSIONS: Many ATs wanted to incorporate EMRs in their clinical practice but faced challenges when attempting to do so. In turn, clinicians often duplicated documentation or used 2 platforms. Athletic trainers should communicate with administrators to select an EMR that fits their documentation needs and seek resources, such as network access and educational opportunities, to learn how to use EMRs.

Clinical management of patients presenting following a sexual assault.

BACKGROUND: Sexual assault is a common and distressing occurrence. The medical needs of individuals presenting in the immediate aftermath of an assault may be obvious: addressing injuries and distress and providing the option of a forensic medical exam. However, the initial assessment and response to a disclosure of sexual assault is an important opportunity to address medical, safety and psychosocial concerns. OBJECTIVE: The aim of this article is to discuss the practitioner's response to disclosures of recent sexual assault and the consequent legal, forensic and medical options. In particular, emergency contraception, sexually transmissible infections and management of injuries may be the patient's predominant concerns. Legal concerns, particularly relating to privacy and documentation, are also important in these cases. DISCUSSION: Following a disclosure of recent sexual assault, a general practitioner may be juggling many concerns, both medical and legal. This article addresses some of these concerns and considers a medical response to a distressing situation in a way that minimises further trauma to the patient and the practitioner.

Clinically accessible tools for documenting the impact of orthostatic intolerance on symptoms and function in ME/CFS.

BACKGROUND: Clinical observations have indicated that hours of upright activity (HUA) reported by Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) patients correlated with orthostatic symptoms and impaired physical function. This study examined the relationship between HUA and orthostatic intolerance (OI). METHODS: Twenty-five female ME/CFS subjects and 25 age and race matched female healthy controls (HCs) were enrolled. Subjects reported HUA (defined as hours per day spent with feet on the floor) and completed questionnaires to assess the impact of OI on daily activities and symptoms. ME/CFS patients were categorized into those with <5 HUA and ≥5 HUA and analyzed by employment status. Data analysis used one-way ANOVA. RESULTS: ME/CFS patients had fewer HUA, worse symptoms and greater interference with daily activities due to OI than HCs. The <5 HUA ME/CFS subjects had more severe OI related symptoms than ≥5 HUA ME/CFS subjects even though OI interfered with daily activities similarly. Only 33% of ME/CFS subjects were employed and all were ≥5 HUA ME/CFS subjects with an average HUA of 8. CONCLUSIONS: ME/CFS subjects experienced more frequent and severe OI symptoms, higher interference with daily activities, and reduced ability to work than HCs. Reported HUA and assessment of OI using standardized instruments may be useful clinical tools for physicians in the diagnosis, treatment and management of ME/CFS patients.

Documenting disability in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS).

BACKGROUND: According to the 2015 National Academy of Medicine report, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) "is a serious, chronic, complex, and systemic disease that frequently and dramatically limits the activities of affected patients." ME/CFS affects between 1 and 2.5 million Americans, leaving as many as 75% unable to work due to physical, cognitive and functional impairment. Unfortunately, many doctors and lawyers lack the knowledge of how to properly document an ME/CFS disability claim, leaving patients unable to access disability benefits. OBJECTIVE: The goal of this article is to summarize the approaches used by experienced clinicians and lawyers in successful ME/CFS disability claims. METHODS: The authors reviewed the types of US disability insurance programs and the evidence commonly required by these programs to demonstrate ME/CFS disability. RESULTS: This article summarizes the range of methods used in successful US disability claims, which include documentation of the functional impact of post-exertional malaise and the use of methods that provide objective evidence of impairment. CONCLUSIONS: Medical providers and lawyers can use these tested methods to obtain disability benefits for people with ME/CFS. Physical therapists, occupational therapists, and other specialists play an important role in providing objective evidence for ME/CFS disability claims.

Impact of Scribes with Flow Coordination Duties on Throughput in an Academic Emergency Department.

INTRODUCTION: With the increasing influence of electronic health records in emergency medicine came concerns of decreasing operational efficiencies. Particularly worrisome was increasing patient length of stay (LOS). Medical scribes were identified to be in a good position to quickly address barriers to treatment delivery and patient flow. The objective of this study was to investigate patient LOS in the mid- and low-acuity zones of an academic emergency department (ED) with and without medical scribes. METHODS: A retrospective cohort study compared patient volume and average LOS between a cohort without scribes and a cohort after the implementation of a scribe-flow coordinator program. Patients were triaged to the mid-acuity Vertical Zone (primarily Emergency Severity Index [ESI] 3) or low-acuity Fast Track (primarily ESI 4 and 5) at a tertiary academic ED. Patients were stratified by treatment zone, acuity level, and disposition. RESULTS: The pre-intervention and post-intervention periods included 8900 patients and 9935 patients, respectively. LOS for patients discharged from the Vertical Zone decreased by 12 minutes from 235 to 223 minutes (p<0.0001, 95% confidence interval [CI], -17,-7) despite a 10% increase in patient volume. For patients admitted from the Vertical Zone, volume increased 13% and LOS remained almost the same, increasing from 225 to 228 minutes (p=0.532, 95% CI, -6,12). For patients discharged from the Fast Track, volume increased 14% and LOS increased six minutes, from 89 to 95 minutes (p<0.0001, 95% CI, 4,9). Predictably, only 1% of Fast Track patients were admitted. CONCLUSION: Despite substantially increased volume, the use of scribes as patient flow facilitators in the mid-acuity zone was associated with decreased LOS. In the low-acuity zone, scribes were not shown to be as effective, perhaps because rapid patient turnover required them to focus on documentation.

The Underreporting of Vision Problems in Statutory Documents of Children with Williams Syndrome and Down Syndrome.

Vision problems can lead to negative developmental outcomes. Children with Williams syndrome and Down syndrome are at higher risk of vision problems, and these are less likely to be detected due to diagnostic overshadowing and difficulty accessing eye-care. Education, Health and Care (EHC) plans are statutory documents, introduced by the Children and Families Act 2014 in England, with the intention of integrating provision across these domains. Vision issues should be reported in these plans, and recommendations made about appropriate adjustments for them. We analysed the EHC plans from 53 children with Down or Williams syndrome. Our results showed significant underreporting, especially for children with Williams syndrome, and little explanation of what adjustments should be made. We also report pockets of good practice.

Prototype of a Military Medic Smartphone Medical Graphical User Interface for Use by Medics in Deployed Environments.

INTRODUCTION: Prompt and effective combat casualty care is essential for decreasing morbidity and mortality during military operations. Similarly, accurate documentation of injuries and treatments enables quality care, both in the immediate postinjury phase and the longer-term recovery. This article describes efforts to prototype a Military Medic Smartphone (MMS) for use by combat medics and other health care providers who work in austere environments. MATERIALS AND METHODS: The MMS design builds on previous electronic health record systems and is based on observations of medic workflows. It provides several functions including a compact yet efficient physiologic monitor, a communications device for telemedicine, a portable reference library, and a recorder of casualty care data from the point of injury rearward to advanced echelons of care. Apps and devices communicate using an open architecture to support different sensors and future expansions. RESULTS: The prototype MMS was field tested during live exercises to generate qualitative feedback from potential users, which provided significant guidance for future enhancements. CONCLUSIONS: The widespread deployment of this type of device will enable more effective health care, limit the impact of battlefield injuries, and save lives.

Predicting Registered Nurses' Behavioural Intention to Use Electronic Documentation System in Home Care: Application of an Adapted Unified Theory of Acceptance and Use of Technology Model.

The use of electronic documentation systems (EDS) has the potential to ensure timely, up-to-date and comprehensive patient health-related information is available and accessible to nurses regardless of their physical location. Despite the benefits of EDS, nurses' low intention to use such systems is well documented, which may predict behavioural usage. Further, limited knowledge exists about nurses' intention to use EDS in the context of home care. The aim of the study was to examine factors that influence nurses' intention of using EDS in home care practice. The conceptual model framing this study is adapted from the Unified Theory of Acceptance and Use of Technology (UTAUT). A cross-sectional design was used. Nurses (N = 217) currently practicing within the home care sector in Ontario participated in the study. An online survey using adapted and psychometrically sound quantitative instruments was administered. Data were analyzed with descriptive statistics and hierarchical linear regression. Performance expectancy, attitude, social influence and facilitating conditions had significant, positive and direct effects on nurses' behavioural intention. Effort expectancy and nurses' individual characteristics (i.e., age, level of education and technology experience) were not found to have a direct and/or moderating influence on nurses' intention to use EDS in home care practice. Theory, practice and research implications for the findings are presented and discussed.

Developing Structured Omaha System Goals for Use in an Electronic Health Record.

Use of standardized terminology has been essential for clear, concise, and accurate documentation of client assessments, care plans, and outcomes. The purpose of this study was to create standardized language goals for a case management system that used the Omaha System. A group of nursing informaticists analyzed, refined, and developed revised goals evaluated using medical vocabulary properties. A set of unique goals aligned with the Omaha System was developed with specifically designed characteristics and functionality that allowed individualization and evaluation of goal attainment. Goal statements and ratings were standardized and written to reflect goals a client could attain. The Omaha System goals served as a template for nurse case managers to use in telephonic support with clients and future development of new goals and allowed the organization the ability to generate quality metrics.

E-portfolio functional requirements for the final semester baccalaureate practicum course: A qualitative research study.

BACKGROUND: The purpose of the nursing practicum course is to enable students to integrate cognitive, psychomotor, and affective skills into professional competencies prior to clinical work. With advances in information technology, e-portfolio focusing on individualized learning, reflection, and self-management has received positive consideration. The nursing profession has since adopted it as part of nursing education. PURPOSE: This study explored the needs and perceptions of students in a baccalaureate nursing program regarding the use of e-portfolio in the final semester practicum course. METHOD: This study used semi-structured focus group interviews and applied the principles of content analysis to interview content. RESULTS: Four key research themes were revealed: (1) anticipated functions achieved, (2) ease of uploading data and showcasing learning results (3) functionality extensions to enhance mobile learning, and (4) policy guidelines for mandatory use and plagiarism prevention. CONCLUSION: E-portfolio assists in integrating knowledge, practical skills, and achievement recognition into the learning process. The use of e-portfolio with upgrades can enable learning of clinical competencies by students in preparation for clinical nursing practice.