This article offers some very good insight here and I’ll add my 2 cents worth as well. We all know that documentation, no matter what kinds it is, paper or electronic is mandatory to good healthcare, but technology creates it own set of new issues too, so it’s not a matter of get electronic records and the documentation issues are solved by any means.
With the current fragmentation of how we record information and the various software programs used, it is a big mess. If a doctor works at more than one hospital with different systems at each one, well they have 2 learning curves now instead of one, and it takes time and training for both, same with nurses and other clinical staff. Thus we have the complaints about healthcare being impersonal due to the interference of computers and other technologies, well it is true. When the complexity overwhelms the purpose of the entire system, we have clinicians more focused on the “how” instead of the “why” we document. Never mind there’s a patient laying there in agonizing pain, let’s make sure we are doing our data input correctly and making sure we have that new update in place and know how to use it, even though it was just rolled out yesterday and perhaps very few on staff have had time to review and see any new revisions on either entering data or more available information, and if you don’t get it right, it could your job.
Both patient care and documentation need to live harmoniously in the same world, no 2 ways about it and both are important, but so is simplicity and balance. I mention this a lot, but having a common user interface that is the same or similar at every hospital and physician’s office is key to survival, otherwise the algorithms keep growing and the new processes appear on the User interface as they are introduced.
How much training in software is required for clinicians? Quite a bit by today’s standards. I like software and just by consulting, how confusing it is for me to keep track of about 10 electronic records systems, well it is not easy at this end either, I have to keep up with all the latest updates and features added, so guess what, the clinicians and IT folks here can finally certainly agree on something when it comes to technology, the need for simplicity and standards.
It’s to the point where even companies like GE want to start over from scratch.
So until such time that vendors group together instead of marketing to the “islands” of healthcare with medical records and documentation we will have “islands” of hospitals and systems, all different at each location and all required some learning curves for all. Health IT with user interfaces and input needs some simplicity enabled soon, otherwise as the continued growth rate of new algorithms being created and frequently added, we may end up with systems that are too complicated for anyone to use. BD
It seems that in this pell-mell rush to incorporate computer technology into patient care, something has been lost. It is the human touch. It is why most of us went into medicine and nursing in the first place. Medicine is the most humane of vocations. We must find a balance to keep it that way.
Gone are the days of business on a handshake. Discussing computers and documentation in a medical column may be a bit odd, but bear with me. It is highly relevant.
A nurse can no longer give a patient in pain a shot without first going down a checklist of questions -- the answers for which must be entered on a computer. Ditto for every other patient interaction. Nurses now spend an inordinate amount of time that should be spent on patient care entering data on a computer.
I think nurses are judged more on the quality of their documentation than on the quality of their patient care. Is it any wonder that burnout is a common occupational hazard of nursing?