Interdisciplinary collaboration and the electronic medical record

Pediatric Nursing,  May-June, 2008  by Shayla D. Green,  Joan D. Thomas

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The future of health care documentation is found in information technology through use of electronic medical records (EMRs). In addition to enhanced accessibility, diverse formatting, and electronic imaging, EMRs are expected to increase the accuracy and precision of important patient data. Paper medical records are viewed as critical components of patients' hospitalizations, yet numerous problems are encountered, such as lost or damaged pages, illegible handwriting, and complex accessibility. Studies have repeatedly shown that "practicing medicine on paper leads to mistakes and poor care" (Stone, 2005, p. 84). Both nurses and physicians expect EMRs to solve many of the previously noted problems found in traditional medical records (Langowski, 2005). However, nurses play the most critical role in documenting the totality of patients' care due to nurses' on-going presence with hospitalized patients (Langowski, 2005).

For five decades, a tertiary care pediatric hospital used a paper system of documentation that heavily relied on nursing narrative notes with minimal use of checklists. Recently the hospital shifted from an all-paper system of patient documentation to an EMR system. The process of selecting the EMR system was initiated by a multidisciplinary team visiting various health care organizations to examine a range of systems. The team was composed of staff nurses, ancillary department representatives, physicians, nurse executives, and other hospital administrators. The team selected a system based on its perceived ability to most accurately and efficiently meet the needs of the pediatric hospital. The system was introduced to each hospital unit by EMR training programs, and the EMR system was implemented throughout the hospital one service line at a time. The "Train the Trainer" model was used as the basis for training expected users of the system. Training was provided to all anticipated users of the system by a team composed of EMR corporate representatives, hospital employed "super-users" who received advanced training, and associates from the nursing informatics department. An onsite command system was established to assist with troubleshooting and problem-solving. EMR users were given unlimited access to the command system during the first two weeks of conversion to the EMR system.

The EMR training provided to nursing staff focused on the use of checklists for nursing assessment and interventions. The checklist format did not provide a simple means to document additional information, such as patient-caregiver interaction, parental nurturing behaviors, or other important psychosocial information. The EMR training instructed nurses to use a separate nursing addendum form to document narrative data not included in checklists. The nursing addendum called for nurses to learn a new problem-oriented approach to patient documentation, known as observation, intervention, and response.

After the EMR system was implemented, physicians voiced concern that the nursing addendum form was frequently incomplete or not used. The hospital's chief nursing officer stated that staff nurses may have perceived narrative data as no longer critical after initiation of the EMR checklist approach to documentation. Further, the risk manager noted negative consequences of insufficient nursing documentation because litigation was frequently settled out of court due to inability to mount effective legal defenses. Nurse leaders also expressed concern that nurses under estimated the significance of narrative patient information when collaborating with physicians. Therefore, the chief nursing officer requested a survey to determine if the EMR enabled nurses and physicians to collaboratively communicate about patient care issues.

Baggs et al. (1999) reported that successful collaboration between nurses and physicians is positively associated with patient outcomes. Effective communication, both written and verbal, between nurses and physicians is a key component of professional collaborations (Casanova et al., 2007; Nelson & Venhaus, 2005). In addition, the EMR is a focal point for nurse/physician communication (Kash, Gamm, Bolin, & Peck, 2005). Therefore, the purpose of this quality improvement project was to examine interdisciplinary collaboration via EMRs. Physicians' perception of nursing documentation is specifically discussed.

Methodology

Participants and setting. The hospital is located in a major metropolitan area in the southeastern United States. It is affiliated with a local academic health science center and serves as the primary pediatric teaching institution. The hospital also serves as the only pediatric tertiary care facility in the region.

The hospital provides a pediatric residency training program, and at the time of this project, seven pediatric faculty physicians supervised the training and education of 33 pediatric residency physicians. Permission to survey physicians was obtained from the chief attending physician's office and the office of the pediatric chief residents. Although the survey was a quality improvement project, the survey was granted exempt status from an Institutional Review Board, and by completing the survey, physicians implied consent to use their responses for data analysis.