Article

By Mary Ann Smeltzer

By now you’ve all seen the headlines or heard the news reports that health care in America is moving toward electronic medical records. Perhaps your hospital, facility, or office is looking at computerized documentation programs; you may already have electronic documentation for some functions. If not, it’s likely that changes will be made at your facility in the near future. Wherever you are on the path to an electronic record, and whatever your site of care delivery, you need to know what impact your facility’s decisions about hardware and software can have on your wound care documentation and outcomes tracking. Take advantage of opportunities to discuss your needs with the professionals heading up any projects that involve electronic record keeping in your facility.

What’s the Buzz?
Electronic medical records have been under discussion for more than 10 years, but President Bush’s endorsement of this technology has provided an impetus for hospitals and other sites of health care delivery, physicians, and insurers to move away from paper documentation and toward electronic records. The appointment of Dr. David J. Brailer as the Bush administration’s national health information technology coordinator has spurred large technology companies to offer products geared toward health care documentation needs. Dr. Brailer himself has asked for recommendations on how to build a national health information network. Wound management, with its historical focus on outcome tracking, is an ideal fit for electronic record keeping.

Where Do You Begin?
What should you be looking for when the time comes to consider electronic records for wound care documentation? How will you know if the software program your facility is considering will really meet the documentation needs for disease management and wound care on your unit or for your program? And if you are the person initiating the move to electronic record keeping, how will you determine which software product is the best fit?

The Department of Health and Human Services is developing a consensus standard for electronic medical records. Providers will need to incorporate core functions in their electronic records in order to receive maximum Medicare/Medicaid reimbursement. In line with this initiative, the Institute of Medicine detailed eight key capabilities that an electronic record should include. You can begin assessing your needs for an electronic documentation system by considering these core functions in relation to how you do business and provide patient care:
• Health information and data
• Result management (of tests and reports)
• Order management
• Decision support (for diagnosis and treatment)
• Electronic communication and connectivity
• Patient support
• Administrative processes (such as scheduling, billing, referrals, and authorizations)
• Reporting
Consider your current work flow and patient information processing. How computer literate are your staff and physicians? Look at the reports you currently use and think about the entire process. Develop an implementable process: who will enter data, and what kinds of data? Point-of-care entry improves the accuracy of reporting and the timeliness of record completion. Drill-down screens and fields enable all levels of users to be efficient in data entry and documentation. Redundant entry should be reduced as much as possible. Programming screens that are “populated” by consistent information save time and improve the accuracy of all personnel who are documenting information.

Format the data entry screens as checklists or multiple choice options. Bear in mind that clinical practice guidelines or treatment protocols that are incorporated into the program will simplify charting and improve compliance with procedures, practices, orders, and formulary. Thus, tracking of services and supplies will be streamlined and measurable. Other issues to consider: Do you intend to eliminate all paper from your records or print hard copies from the program and file these in permanent charts? Will the program allow you to incorporate wound photos? Will it meet your needs for data capture to support billing and regulatory requirements? And who will be allowed access to all this information?

Asking the Hard(ware) Questions
Operationally, will you use point-of-service data entry as care is provided? If so, can you have a workstation in every room, or would mobile workstations or handheld devices be a better and more cost-effective choice? Do you have the ability to use a wireless connection in your unit or facility? Some programs are Internet based; others reside on individual computer stations or servers. If your program data is stored locally, what are the options for backup of data, and will your staff need to be involved in that process?

You’ll need to know your medical records requirements for format of hard-copy forms and documents. Any documentation that is printed out should include your hospital or facility name and logo. All entries should be time stamped and dated. Computerized documentation programs should automate tasks that you currently do manually, such as quality management data collection and trend analysis.

Have It Your Way
An electronic record for wound management can save you time and reduce your expenses. Even more important, it can improve patient care quality and reduce errors. Conversely, an electronic record can be a hindrance if the program you use fails to address your specific needs, is not user-friendly, or requires double capture of information. If it is impossible to incorporate electronic documentation into your work flow, or if data entry sites are not accessible at the point of care provision, users might see computerization as an imposition and a hardship. If electronic documentation is in your future, it is well worth your time to begin looking at your needs and desires now, before you select a software provider or have one selected for you.

Mary Ann Smeltzer is a master’s-prepared nurse certified in wound care by WOCNB with more than 25 years of nursing experience, over eight of those in wound care. She has held positions in nurse management, in education, and as a legal nurse consultant, and has provided clinical support, education, and quality oversight to more than 22 wound programs. She is currently director of clinical operations for Net Health Systems, Inc., creator of the WoundExpert® software for electronic documentation and outcomes management for wound care and hyperbaric oxygen therapy. Ms. Smeltzer is also a disease-specific care program reviewer for JCAHO and an adjunct faculty member at Community College of Allegheny County.