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1995 Computerized Patient Records and NP Practice. Polly A. Hulme South Dakota State University, [email protected]

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Recommended Citation Hulme, Polly A., "Computerized Patient Records and NP Practice." (1995). College of Nursing Faculty Publications. 56. http://openprairie.sdstate.edu/con_pubs/56

This Article is brought to you for free and open access by the College of Nursing at Open PRAIRIE: Open Public Research Access Institutional Repository and Information Exchange. It has been accepted for inclusion in College of Nursing Faculty Publications by an authorized administrator of Open PRAIRIE: Open Public Research Access Institutional Repository and Information Exchange. For more information, please contact [email protected]. NPnews Computerized Patient Records and NP Practice Computer-based patient records in; the entry is then automatically coded the user as information. There are sev­ (CPRs) are becoming increasingly com­ for storage. Coded data save storage eral levels of information systems used mon in ambulatory settings. The advan­ space and render the data ready for in health care. At the patient level are tages of computer-based patient re­ statistical analysis. clinical information systems. The CPR is cords over paper records are multiple: Data can also be entered using free a clinical information system, because it they save space and time, help health text. Free text is the usual mode of aids in the management and documen­ care providers improve patient care, organizing data for providers. However, tation of patient care. At the administra­ and provide clinical and managerial the major disadvantage of free text is the tive level, management information sys­ information quickly. Currently, however, difficulty of retrieving data across re­ tems help administrators manage the this software is based on the medical cords. Although some free text is una­ delivery of health care. Quality assess­ model. voidable, a CPR completely in free text ment and improvement (QAI) programs The software for computer-based is merely an "electronic piece of paper" are an example of the use of this type of patient records was developed about with little improvement over the paper information. Good CPR software will 25 years ago in academic health care record. In contrast, CPRs that have at elicit data for both clinical and manage­ settings, but was never disseminated least some structure have numerous ment information systems. Research extensively into other types of ambula­ advantages over paper records. can be conducted using information tory settings. Now, however, with the from either level. advent of more powerful personal com­ Advantages of CPRs Clinical information systems can be puters (PCs), this innovation is commer­ There are four major advantages of further divided into hospital and ambu­ cially available for smaller ambulatory CPRs: they save space, save time, latory systems. Nursing information sys­ practices. improve patient care, and serve as tems, which help nurses manage and While advanced practice nurses information systems. A single hard disk document patient care, are increasingly (APNs) can use this software as readily holds thousands of records and takes evident in hospital systems, but not so in as physicians, they also have a perfect up only a few inches of space. The ambulatory systems. The absence of opportunity to add the nursing data that tapes used for daily backup take up nursing information in ambulatory clini­ differentiate their practices from that of about the same amount of space. cal information systems is particularly physicians. The addition of standard­ Time can be saved in many ways. detrimental for APNs during periods of ized nursing data to computer-based For example, completed encounter potential health care reform, since infor­ patient record software would help forms, physical examinations, and other mation from aggregated information APNs integrate nursing diagnoses, in­ customized reports can be quickly gen­ systems is what often drives public terventions, and outcomes into their erated, as well as flow sheets or labora­ policy at the local, state, and federal management plan; and facilitate re­ tory reports. Telephone consultations levels. With the increasing use of CPRs search on advanced practice nursing. can be done instantaneously since the in ambulatory settings, however, APNs Software vendors need to be encour­ provider always has the chart on hand. have an ideal chance to document the aged to fully integrate standardized Workstations in multiple sites, including advanced nursing care they provide nursing data into CPR software so APNs the examining rooms, allow instant re­ patients. can fully document their practice, im­ trieval and entry into patient records. Examples of CPR Software prove patient care, and facilitate nursing Some programs will automatically place research. a prescription on the medication list, The earliest CPRs were developed progress note, and on the prescription almost 25 years ago in academic cen­ Improved Capabilities blank itself with only one entry. Key word ters, but their dissemination to ambula­ Most CPR software programs use a searches can be used to find notes on tory settings outside large health main­ database format to collect the data into an old problem. And at least one piece tenance organizations (HMOs) and aca­ files and a database management sys­ of available software allows patients to demic settings has been disappoint­ tem to manage and access the data. type their own health histories into the ingly slow. Three well known early sys­ The more powerful PCs allow the stor­ computer using a multiple choice for­ tems still in use are the Computer Stored age and management of the large mat. The computer then assimilates the Ambulatory Records System (COSTAR)

IISIrn"ll",ta nf nato nAAn,al"'l fnr ~cn:::Ia l"'4ata. ''''tl''\a ru:t.rra,tl\JA fnr", that "an n.c. rtAvAlnnArt At HArvArd LJnlvAnlitv. ThA ,...... ""',.,,,'".... ,. '''' 1o/"""10''''.'"IJ._'''I VI .""'1,.,"-, "'..".,,.,,.,.'" •. I"'VWI I.. ' ~"'m'., n•• nn car. ~n~rm, .,nc. ,mor" patient record software would help forms, physical examinations, and other matlon from aggregated information APNs integrate nursing diagnoses, in­ customized reports can be quickly gen­ systems is what often drives public terventions, and outcomes into their erated, as well as flow sheets or labora­ policy at the local, state, and federal management plan; and facilitate re­ tory reports. Telephone consultations levels. With the increasing use of CPRs search on advanced practice nursing. can be done instantaneously since the in ambulatory settings, however, APNs Software vendors need to be encour­ provider always has the chart on hand. have an ideal chance to document the aged to fully integrate standardized Workstations in multiple sites, including advanced nursing care they provide nursing data into CPR software so APNs the examining rooms, allow instant re­ patients. can fully document their practice, im­ trieval and entry into patient records. prove patient care, and facilitate nursing Some programs will automatically place Example. of CPR Software research. a prescription on the medication list, The earliest CPRs were developed progress note, and on the prescription almost 25 years ago in academic cen­ Improved Capabilities blank itself with only one entry. Key word ters, but their dissemination to ambula­ Most CPR software programs use a searches can be used to find notes on tory settings outside large health main­ database format to collect the data into an old problem. And at least one piece tenance organizations (HMOs) and aca­ files and a database management sys­ of available software allows patients to demic settings has been disappoint­ tem to manage and access the data. type their own health histories into the ingly slow. Three well known early sys­ The more powerful PCs allow the stor­ computer using a multiple choice for­ tems still in use are the Computer Stored age and management of the large mat. The computer then assimilates the Ambulatory Records System (COSTAR) amounts of data needed for CPRs, data into a narrative form that can be developed at Harvard University, The allowing smaller practices to take ad­ reviewed and corrected with the patient. Medical Record (TMR) developed at vantage of the software technology. CPRs can improve patient care in Duke University, and the Regenstrief Another technological advance is multiple ways. For example, individual­ Medical Information System (RMIS) local area network (LAN) software, ized patient instruction sheets, reports devloped at the University of Indiana. which electronically links a number of on delinquent tests for the entire prac­ The RMIS, which is the least wide­ computers to the PC with the CPR tice, and family linked medical records spread, was one of the first programs to software and data (called the "file­ can all aid in providing better patient include a computerized medical knowl­ server"). Thus, multiple users in a prac­ care. Before consulting with a patient, edge base. tice setting can share data, software, the provider can reformat information A new program, the Intelligent Medi­ and even printers. Additionally, mo­ from the patient record to address the cal Record-Entry (IMR-E), has been dems can be used to access records current problem or to create a patient recently developed by a team called when outside the usual care setting. summary. Decision making is enhanced MEDAS, whose members come from Security measures, such as the use of by the more structured CPRs, because several universities. Unlike the other passwords, help to prevent unauthor­ the data entry template prompts the programs, data can only be entered by ized access to the system. gathering of complete data, which then providers. The IMR-E's data entry is the Data are entered as much as possi­ will be available when needed. Further, most structured of the academic pro­ ble on templates in coded form. A decision support in the form of provider grams, but it is also the most user template designates certain areas of reminders of preventive care and other friendly, since it uses icons and a each record for specific data, such as alerts, such as drug incompatibility, is graphical user interface. the problem list. By structuring the data, available in many CPRs. Individualized Lately, CPR software has been intro­ the computer can more easily retrieve patient reminder letters can be gener­ duced by commercial software compa­ data within and across records. The use ated from this programming as well. This nies, who already have a market with of coded data facilitates data entry, is accomplished by programming rules clinics and private practices. Many of storage, and analysis. Vocabulary is into the software that electronically de­ these ambulatory settings have long standardized to allow a common under­ termine when reminders or alerts are employed "office practice management" standing among the multiple users of issued. software to handle billing and accounting the program. There usually is no need to Finally, CPRs are ideal information functions. With more powerful PCs avail­ memorize codes, since many programs systems. Data, in uninterpreted form, able, a logical extension of this business have text prompts to choose from, or such as an ICD-10 code, is organized has been to add CPR modules to billing allow the standardized text to be typed and interpreted to convey meaning to Please see Patient Records page 5

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Continued from page 4 the medical model of patient care, which cludes symptom control, counseling, described using nursing rather than is generally disease oriented. APNs can teaching, and case management, all of medical diagnoses, interventions, and Patient Records and do use this software to document which have been considered nursing outcomes. systems. However, these CPR modules their care, but it only partially captures interventions. And finally, documenta­ The addition of nursing diagnoses, sometimes contain little structure with their own model of patient care, which is tion of the impact of APN care is not interventions, and outcomes to CPR soft­ individual, family, and community ori­ complete without the measurement of few coding requirements. Further, many ware would not only better capture the ented rather than disease oriented. outcomes. Health status, functional are developed by financial or computer APN's unique model of patient care, but The management of acute and status, quality of life, and patient prefer­ experts who do not have the clinical would also provide a wealth of much background necessary to structure a chronic health problems by APNs in­ ences are all examples of outcomes volves not only diagnosis of diseases, consistent with nursing, whereas mor­ needed data on APN practice that could CPR adequately into a time saving tool. address numerous research questions. Some commercial CPR modules, there­ but also the diagnosis of individual, bidity, mortality, and clinical indicators For example, this data could help sub­ fore, are merely "electronic pieces of family, or community responses to these are outcomes closely tied to the medical stantiate and differentiate the practice of paper" that only save space, with little health problems. Likewise, the treat­ model. Health promotion, health mainte­ capacity for generating clinical and man­ ment of health problems does not stop nance, and prevention are additional APNs from physicians in a quantitative agerial information. with medical prescription, but also in­ APN activities that can more readily be Please see Patient Records page 13 Two popular commercial software CPRs that do function as information systems are Practice Partner Patient Records (PPPR) published by Physician Micro Systems, Inc., in Seattle, Wash­ ington, and Medical Manager (MM) published by Systems Plus, Inc., in Mountain View, California. PPPR con­ tains all the elements found in paper charts, including the problem list, pro­ gress notes, vital signs, medical history, social history, family history, the medica­ tion list, immunizations, health mainte­ nance, and laboratory results. When a progress note is entered, all parts of the chart are automatically updated. PPPR can generate chart summaries; pro­ gress notes by visit or problem; flow­ charts of laboratory values, vital signs, and medications; and preventive meas­ ures due for each patient. Laboratory values from outside the practice can be automatically loaded by modem and recorded in the correct section of the record. Letters and consultation reports can also be entered by merely using an optical scanner. MM has similar fea­ tures, plus a newly developed Data Merge Language, which allows sharing data with a hospital computer. Cost· Benefits The costs of CPR software and the hardware necessary to support it are still substantial. Installation and operating chart are automaticallyupdated. PPPR can generate chart summaries; pro­ gress notes by visit or problem; flow­ charts of laboratory values, vital signs, and medications; and preventive meas­ ures due for each patient. Laboratory values from outside the practice can be automatically loaded by modem and recorded in the correct section of the record. Letters and consultation reports can also be entered by merely using an optical scanner. MM has similar fea­ tures, plus a newly developed Data Merge Language, which allows sharing data with a hospital computer. Cost· Benefits The costs of CPR software and the hardware necessary to support it are still substantial. Installation and operating costs are additional costs to be consid­ ered. As mentioned above, the benefits of CPRs to be weighed against costs include savings in space and time, improved patient care, and the contribu­ tions of an information system that can be used for managing patient care, QAI, and research. Costs can be compensated some­ what by decreased expenditures for medical records personnel, paper sup­ plies, and space, and by improved accounts receivable from computerized billing. Costs can also be lowered if providers enter their own data. Choos­ ing hardware, software, and vendors carefully is another method of keeping costs down by avoiding purchase of an inadequate, unnecessary, or already obsolete system. The American Nurses Association has published an excellent booklet on choosing a system entitled "Computer Design Criteria: For Systems That Support the Nursing Process" by Zielstorff, McHugh, and Clinton. Addi­ tionally, the journal M.O.Computing often has good articles on the subject. Adding Nursing Data to CPRs All of the available CPR software for use in ambulatory settings are based or, NPnews

Continued from page 5 psychological data classification sys­ out having to enter them word by word. Patient Records tems are the CPT, ICD-10, and DSM-IV This is being done for nursing care Benefits From the codes. The American Nurses' Associa­ planning in hospital systems, but the Use ofCPRs way. Until now, these differences have tion (ANA), since 1980, has been ac­ requirements of APNs are different. According to a report in the February been difficult to describe without relying tively promoting and developing a clas­ Nursing diagnoses, interventions, and sification system which despite consid­ outcomes need to be completely inte­ 6, 1995. American Medical News, a on qualitative descriptors. CPRs contain­ number of insurers are offering reduced ing nursing diagnoses, interventions, erable progress is still far from com­ grated with the medical management prof~ssionatliability premiums to physi­ plete. The ANA believes that only by format. In other words, where medical and outcomes would also expedite the cians who. use certain medical record study of access, cost-effectiveness, naming what nurses do and assigning a diagnoses are to be entered, there systems. The reductions range frQm2%­ quality, and productivity of APNs. While computer code to that name, will nurses should be space for nursing diagnoses. 5%. The rationale behind such reductions many studies were done on these sub­ be directly reimbursed and recognized Likewise, nursing interventions should is that many malpractice suits are.won or jects in the 1970s and early 1980s, far as a profession with unique skills and be entered as part of the management lost on the quality and content of patient fewer are being conducted now. Specifi­ knowledge. plan. Nursing outcomes are not always records. In addition, electronic record systems provide reminders to help pro­ cally, access could be studied by exam­ Standardized nursing data classifi­ evident in ambulatory settings, but viders give comprehensive care. warn of cation systems currently accepted by could be entered in a follow-up note. ining the zip codes and insurance status drug interactions, and monitor follow.up the ANA are NANDA (North American All entries should have their own of patients being seen in the practice. and patient compliance.• Cost-effectiveness could be studied by Nursing Diagnosis Association), NIC structure and location, yet have links to looking at the prescribing habits, labora­ (Nursing Interventions Classification all other entries in the record, so a tory use, patient follow-up, clinic revisit System), the Home Health Care Classifi­ particular patient's nursing interven­ Continued from page 7 rate, and revenue generated by various cation System from Georgetown Univer­ tions, for example, could be linked to his types of providers. Quality studies could sity, and the Omaha System for Home or her nursing diagnosis and medical Association News Health Care. Standardized nursing out­ diagnosis. Summary sheets and en­ address selected patient outcomes and eligibilty criteria for certification as a comes are in the process of being counter sheets would all need to include satisfaction. Patient satisfaction could be gerontological nurse practitioner. Geron­ developed by the Nursing-Sensitive pertinent nursing data along with medi­ directly enterd into the computer by tological nurse practitioner candidates Outcomes Classification Research cal data. On the other hand, nursing patients at each visit to track changes will need to have completed master's Team (NOC) at the University of Iowa data should be retrievable by itself. With over time. Productivity could be meas­ degrees in a gerontological nurse practi­ College of Nursing. Much work remains, such a CPR, APNs would find a valuable ured by using a tool recently developed tioner program. In 1995, master's de­ tool that not only saves space and time by APNs that uses a computer program especially in integrating the diagnosis, grees from adult and family nurse prac­ and improves patient care, but also to link the total time spent with patients of intervention, and outcome classification titioner programs and certifications from serves as an information system that various levels of complexity to patient systems. However, the use of these gerontological, adult, or family nurse efficiently documents all aspects of their billing (see The Nurse Practitioner systems now to document nursing care practitioner programs will remain accept­ unique practice. 1992;17(4):50,52,55). APNs could be is crucial. able. Currently certified gerontological CPRs are becoming increasingly studied across practices as well as Commercial software companies nurse practitioners will not need to meet more affordable in all types of ambula­ within, for access, cost-effectiveness, and vendors need to know their CPR the new requirement, provided they apply tory health care settings. However, quality, and productivity. The ability to software for ambulatory settings is not for recertification before their current influence health policy at all levels is an adequate for APNs. Some vendors state CPRs in their present form are based on certification expires .• achievable goal with this type of re­ there is ample flexibility in their product the medical model. The integration of search. to add nursing data as the customer standardized nursing data into the med­ Oncology Nursing Month sees fit. However, this is not an ade­ ical management format of CPR soft­ Announced Standardizing Nursing Data quate response. Standardized nursing ware would allow APNs to take full The Oncology Nursing Society has If nursing data is to be programmed data classification systems, particularly advantage of the technology to com­ announced that April 25-May 31, 1995 is into CPR software used in ambulatory NANDA, NIC, and the eventual nursing pletely document their practice, and in Oncology Nursing Month. For a free settings, it is essential to use standard­ outcomes classifications, should be the process to improve patient care and promotional guide or further information, ized nursing data that have been classi­ programmed directly into the software facilitate research .• contact: Oncology Nursing Society, 501 fied into an acceptable taxonomy. Ex­ so APNs can quickly document their Polly A. Hulme, MSN, ARNP Holiday Dr., Pittsburgh, PA 15220; (412) amples of standardized medical and activities in a standardized format with­ Iowa City, Iowa 921-7373 or fax (412) 921-6565 .•