Questions – Answers – References
Light blue means DONE!
(Taskforce Member) / Data or Evidence? / Reference/Source / Date
5 / Error correction
Format for errors / What type of format should be used to indicate errors or changed documentation?
Should the older data be displayed?
How is the completed history of data configured? (audit trail)
“Error explanations– changes – how much should be in strikethrough format? Or should it be in that format?” / It is vendor-specific, but strike-through is common.
Some systems display it with strikethrough, some have the erroneous data display removed from view.( This is often configurable.)
Since clinical decisions are based on data, it is important to at least be able to see what the prior data was. The clinician needs to know that the data was changed.
Can it be configured to one standard?
CHIT standard is Show the original, the date/time of the error - and provided the ability to maintain it.
AHIMA - Especially refers to physician documentation. Most physicians have addendums, rather than strikethrough, even on paper. / Lisa Bove
Julie Luengas / CHIT /
24 / Policy
Documentation / What policies should be addressed prior to electronic documentation design/implementation? / Procedure Policies:
All documentation policies should be reviewed/revised to accommodate electronic documentation.
Design should take policy requirements into consideration.
Should include the following for electronic and paper documentation: What should be documented, where it should be documented and the frequency the information should be documented. For example, IV catheter, document the gauge, site location, site appearance, patency, number of attempts (for insertion) in the IV Catheter form in the EMR. Site inspection should be documented in the IV Cather form every hour in the EMR
In the event of downtime, on the nursing paper flowsheet document the IV catheter, document the gauge, site location, site appearance, patency, number of attempts (for insertion). IV site inspection should be documented on the paper flowsheet every hour.
Consider the wisdom of including the name of the form for that documentation – the form names may change or the documentation of the item may be on a different form. / Jim Cato
8 / What is the best practice for maintaining the power supply on mobile devices? / Create labeled docking stations.
Education: the mobile computer is like a crash cart – it needs to be plugged in.
Have Engineering evaluate power supply in the area. Ensure that power plugs are at waist level to prevent injuries.
Consider replacing the DVD/CD drive with an extra battery.
Keep a local supply of spare batteries.
As batteries age, they are less efficient and hold a charge for a shorter period of time.
For home care/hospice, management of batteries is important; many homes won’t have the space to access power. / Jim Cato
9 / Jim will get formula / How is the appropriate number of documentation devices determined? / One device per nurse.
Vendors, as part of the implementation, have a consultant that uses a formula to calculate this. It may be possible to use fewer devices if, for example, aides used devices while the nurses are in report.
Have at least 2 carts for spares.
Include nurses’ aides, ancillary providers (PT, RT, physicians) One type of device may not fit all providers. / Adams, J., Williams, V, Schirmet, L et al. “Setting Metrics for Identifying Point-of-Care Devices: Experiences From the Field.” CIN: Computers, Informatics, Nursing 25.5 (2007) 309.
11 / Default
Point of care documentation
Choice lists / Are ‘default’ answers in forms permitted? / Default answers allow for quicker data entry, but should be used judiciously so that users don’t miss the need to change from the default to the correct option.
When making this decision, the following should be considered:
Have you allowed defaults on paper forms or in other applications? If so, then these defaults should be reviewed to determine if they are still appropriate for an electronic form.
Consider one of the ways to determine that a question can have a defaulted answer is if the default option ‘correct’ at least 80% of the time.
Ensure that the end-user can easily change the default answer.
Consider where the option is located or how easy it is to view the other options.
Review with Compliance Officer/Risk Management.
Can your electronic system ‘remember’ previous responses that are patient specific?
Can your system identify items that were defaults (as opposed to selected from a choice)?
(If you've elected to use the 'copy forward' function, the default option should not be used in conjunction with 'copy forward'.) / Lisa Bove
17 / Enhancement request
Vendor / What is current practice for enhancement request prioritization? (hospital)
How are clinical enhancement requests reviewed? Does the review of clinical enhancement requests include an assessment of the clinical impact of the changes?
What is current practice for communication of system-related changes, enhancements? (Hospital)
How are enhancement requests communicated to a vendor? /
- Committee which reviews all Clinical requests to change the EMR-except for charge and drug changes.
- Committee prioritizes the requests by Must Have (safety or regulatory) vs Nice to Have (makes it easier to perform in the EMR, but currently can be performed, but with extra effort by the clinician.
- All requests, the week prior to building into production, are reviewed and approved by a technical team.
- Create communication plan to end users as part of the change management process.
- Vendors want to respond to users' needs.
- The vendor will create a patch, fix or version to address requests.
- Requests are submitted to the vendor - the request goes to a internal vendor who assesses:
- The impact of the change
- Resources needed to complete change
- Priority based on number of user requests - safety and regulatory changes are first priority.
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? / Most organizations are using classroom or computer-based training or a combination of methods (blended learning solutions) to deliver training. Super users appear to be widely used to support training and are usually given extra training in addition to the standard end user training. It appears that super users are more often utilized as training support staff rather than actual trainers. / Edwards, P. (2006). Electronic medical records and computerized physician order entry: Examining factors and methods that foster clinician IT acceptance in pediatric hospitals. United States -- Georgia, Georgia Institute of Technology: 298.
The HIMSS Nursing Informatics Awareness Task Force, (2007). "An emerging giant nursing informatics." Nursing Management38(3): 38-42.
Kulhanek, B. (2010). Enablers, barriers, and the influence of organizational environmental factors on computerized clinical documentation training developed and delivered by nursing informaticists. Manuscript in preparation.
22 / What testing is necessary for electronic systems?
Who should do the testing pre-implementation? Is post implementation testing necessary? / Link to ONC Certification Criteria. / Julie Luengas
Melissa Barthold / Mark will send citations.
23 / Brenda – waiting for Brenda’s data / How is standardization of documentation of practice analyzed, implemented and measured? /
- Implement a nursing terminology
- Discourage the amount of free text data entry.
- Utilize a commercial product - evidence-based - to maintain standard verbiage.
24 / Mental health
HIPAA regulations for mental health
VIP / What is the current state of EHR use in mental health? / No specific recommendation about EHR and mental health available from American Psychiatric Nurses Association.
Concerns about security/privacy can block caregivers access. Caregivers involved in the patient's care must have access to the entire medical record, including psychiatric information.
Psychiatric information should have an additional layer of security: requiring a reason to view the record, as well as audit trails.
HITSP does not address the question.
Develop policy on assigning security rights to staff permitted to view mental health documentation. Create strong audit trail.
These same concerns/policies should be applied to information about HIV, any VIP patients, patients with substance abuse. / Melissa Barthold
Lisa Bove / American Psychiatric Nurses Association
American National Standards Institute
Security and Privacy Scope. June 1, 2010. HITSP
25 / How are ancillary departments trained to use the EHR? / Each ancillary discipline usually defines their own education. Pharmacy has developed an entire informatics discipline.
Most ancillary departments conduct their own training, similar to the nursing model.
Ancillary staff tend to have less formal orientation, and more on-the-job training than classroom or competency based instruction. (There are smaller numbers of ancillary staff hired at one time, which can affect the class structure.)
There are a number of resources available for the ancillary departments.
Training other staff – including billing, HIM, coders – has to be included. Most IT departments don’t have ancillary representation – nursing informatics usually cover it.
It’s possible to train all staff together, if the documentation used is similar enough.
/ Melissa Barthold
Robert McKell / HIMSS Clinical Informatics Insights
Hagland, M. Rowing together. Healthcare Informatics. July, 2010.
Civa, S. “Informtion technology: teach your clinicians the skills they need to succeed.” CARING 28.7 (2009) 48-51.
26 / Infection control
Washable equipment / 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 / Cleaning procedures are dependent on vendor recommendations as to the disinfection solutions that each piece of equipment will handle.
Some institutions have installed washable keyboard covers and/or washable keyboards.
Recommendations from articles are that equipment should be routinely disinfected. (There is no apparent definition of 'routine'.)
Some infection control staff recommend that computers are cleaned as any other device is cleaned.
Staff responsible can range from environmental services to nurses' aides to professional nurses. / Lisa Bove
Melissa Barthold / Dumford, D., Nerandzic, M., Eckstein, B., Donskey, C. American Journal of Infection Control. 2009; 37, 1 5-9.
Hartman, B, Benson, M., Junger, A., Quinzio L., & Ro, R. Computer keyboard and mouse as a reservoir of pathogens in an intensive care unit. Journal of Clinical Monitoring and Computing. 2004;18:1:7.
Your hands may be clean, but is equipment dirty? 2010. Journal of ED NursingI. March, 2010.
Leander, J., Burke, R., Sulis, C., & Carling, P. Dangerous cows: An analysis of disinfection cleaning of computer keyboards on wheels. American Journal of Infection Control. 2009; 37: 778-80.
Neely, A. N. and D. F. Sittig (2002). "Basic Microbiologic and Infection Control Information to Reduce the Potential Transmission of Pathogens to Patients via Computer Hardware [Electronic Version at Journal of the American Medical Informatics Association 9(5): 500-508.
Rutala, W. A., M. S. White, et al. (2006). Bacterial contamination of keyboards: efficacy and functional impact of disinfectants [Electronic Version at Infection Control Hospital Epidemiology 27(4): 372-7.
Wike, G. (2008, November 6). Far-UV Light Disinfection of Hospital Computer Keyboards. Retrieved March 25, 2009, from
29 / Sound cards
Clinical units / 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 / Many organizations include sound cards in all computers, basically because of computer based education for both staff and patients.
Some organizations have elected not to have sound cards/speakers installed - so audio is not available on those pc's. / Melissa Barthold
Jim Cato / 8-18-09
31 / CPOE
Verbal order read back / How are telephone or verbal orders handled in a CPOE environment?
Protocols - how are drug, diagnostic and imaging orders placed by nurses under a protocol when no physician doesn't sign them directly. In the paper world, there was a signed protocol in the Administration office that validated that order. Does the system require choosing a doctor or is a protocol ok? Especially applies to ED and newborn nursery. / No policy for telephone orders, the mandatory use of CPOE is
in the orientation for the medical staff as well as the nursing staff.
Our workflow for this is as follows:
1. All orders are in CPOE - no exceptions
2. No verbal orders are taken for CPOE unless in an emergent situation
with all hands needed on patient
3. no phone orders except in following case:
a. RN calls with abnormal test result or patient care need and
patient needs treatment related to this
b. MD is in transit from one place to another and cannot access
computer - no more than 6 orders is our guideline on this, just enough
to get patient care initiated.VORB: Verbal order readback: Note that MD MUST remain on phone
while RN is entering the orders so that they can reply to any alerts the RN
encounters when entering orders as well as permit the RN to read the order back at completion.
c. if verbal orders are requested, we ask that pathway orders or order sets be accessed as orders are pre-checked and RN can read the orders back to MD with rare/few changes.
Most protocols/guidelines are signed by physicians and in place in areas such as Nursery, ED, L&D - areas where the standard of care requires many of the same things for each patient. (This would include fetal monitoring for labor patients, Erythomycin eye ointment for newborns and beta blockers for MI patients.)
In the electronic world, the orders can be placed by the nurse, with an indication that this is a protocol order - but the signed protocol (paper) still should be available in the administrative offices. / Connie Whittington (personal communication) / Oct 13-09
33 / Core measures
Alerts about core measure patients
Problem list / How are core measure patients identified in the system? How are appropriate people alerted? / Dependent on system functionality
Proposed Rule requires problem-based list.
Each system must have a problem-based list that can be extracted electronically to permit/encourage clinical decision support and research on aggregate patients.
Vendors can assist with standardization of these measures in their system by designing automated solutions based on Snomed or ICD-9 codes and creating mini-applications to permit easy identification of core measure patients. / Julie Luengas
Melissa Barthold / Certification Commission for Health Information Technology
Federal Register, January 13, 2010. Medicare and Medicaid Programs; Electronic Health Record Incentive Program, Proposed Rule.
34 / Robert / How is the flow of information/communication managed between inpatient units, the Perioperative area and back - including pharmacy. How are the different systems involved?
35 / Is best of breed better - or integrated system better?
36 / Jullie will look for evidence. / How is the clinical staff notified of a patient's need for isolation, based on lab results from a prior admission? / Clinical alerts can be based on:
Prior lab results - few staff members have the time to review labs from previous admissions. Some results would continue to require isolation (e.g. MDRO, VRE) while others (C-DIFF) may not require on the admission.
Clinical staff should be alerted about patients in the first category so that appropriate action should be taken. The alert should be generated as soon as the patient is admitted, hopefully prior to the patient's admission to the nursing unit.
If isolation is based on hospital policy, an automatic order set could be created that would be activated on the patient's admission (after approval by MEC and Infection Control Department.) / Jane McNeive
Melissa Barthold / Larson, E, Cohen, B, Ross, B & Behta, M. “Isolation Precautions for Methcillin-Resistant Staphylococcus Aureus: Electronic Surveillance to Monitor Adherence. American Journal of Critical Care 13.1 (2010): 16-26
Magnus, M. Herwehe, J., Andrews, L, Gibson, L, et al. “Evaluating Health Information Technology: Provider Satisfaction with an HIV-Specfic, Electronic Clinical Management and Reporting System.. ADS Patient Care & STD’s 23.2 (2009): 85-91.
Robeznieks, A. “Doctors are beginning to accept e-alerts: study”. Modern Healthcare 36.3 (2006)
Juster, I. “Technology-driven Interactive Care Management Identifies and Resolves More Clinical Issues than a Claims-Based Alerting System. Disease Management 8.3 (2005) 188-197
37 / New orders
Notification to RN
New order alerts
Communication / How are nurses notified of new orders in a CPOE environment? / System dependent.
One system's process:
After order is entered - it appears as a red flag in 'New Orders'. This 'New Orders' column appears on several different screens that are frequently used by nurses. The actual order appears on the Task List. Once order is acknowledged, it removes the flag for that nurse. (This is core function of a system.)
Another system uses the clerk to send a text message of the copied/pasted order to the nurse's VoIP phone.
Some systems use an electronic status board - tv screen hung on the wall in different parts of the unit to display the census with an indicator of a new order.