Folk rock fans might remember Loudon Wainwright singing, “We’ve come a long way since we last shook hands. Still got a long way to go.” That line pretty much sums up the evolution of documentation, data capture and performance improvement efforts over the past 10 years in the field of wound management. Ten years ago, few of us imagined that we’d be trading in our paper records for computer stations and hand-held electronic devices, and we had no clue what EMR, PHI, HIM, PPS, and all the other alphabet-soup-like labels commonly used today in reference to health care information might mean. Technological advances in health care information management have changed all our lives and brought some great rewards (along with significant pain in the process of working toward those rewards).
The reasons that we document information in patient records haven’t really changed, but how we use that information has expanded far beyond a record of who did what when, and how it turned out. We still need to communicate assessment and care planning information to other caregivers to ensure that we’re all on the same track and progressing toward the same goals. We still need to have a legal record to demonstrate that the care provided was appropriate and in line with accepted standards of practice and relevant assessment information. We still need to have proof of what we used or did, and why, in order to receive payment for services.
However, we probably never imagined how much more that particular charted information could tell us about how efficient and effective we are in caring for entire groups of patients and if we do as well as others caring for the same kinds of patients. We never dreamed that knowing that information might change exactly how much we get paid for the work we do or that it could tell us how to do better in the future. Who would have guessed that surveyors and reviewers would go from, “If it wasn’t charted, it wasn’t done,” to “Help me see and understand why you do what you do and how that conforms to evidence-based practice for your specialty”?
We have all experienced multiple revisions of paper forms and the introduction of new ones to meet each new national standard for some regulatory body or other. I bet there are few among us who have not participated in some type of chart audit to either evaluate conformance to a standard or collect data for some quality initiative. Many of those reading this commentary are responsible for collecting and reporting quality management data, or for monitoring use and efficacy of products and services, or even managing patient flow and physician/clinician scheduling to enhance productivity. I can hear your collective groans when you summarize what it takes to accomplish these tasks if you must hand-search records and compile lists of data to analyze—for analyze and report you must, no matter how you accomplish it.
Fortunately, as the demands for data collection and analysis increased and the need to improve efficiency and cost-effective resource management grew, technology was developed to make those chores more manageable. In wound management, limited resources and reimbursement changes have partially spurred a need to determine what works and what doesn’t and whether the benefit of an action/product outweighs its cost. Over the years, wound management programs and wound care providers have become more focused on clinical outcomes such as wound healing rates and days on service to heal a wound. What started out as marketing data to help grow a business or provide a case for preferred provider status, or justification to implement a wound program in a facility, led to efforts to find out why some patients or programs have better outcomes than others. More and more research focused on comparisons among types of patients, types of products and interventions that led to the current focus on evidence-based practice and evaluations of appropriateness of care.
Technology provided software programs that permitted entry of data points from patient records to determine outcomes and allowed benchmarking against one’s own previous performance (or that of similar programs or providers), faster and with less human involvement. Many health care professionals now rely on these outcome and benchmarking programs to evaluate performance over time and to make decisions about how to care for individual patients or groups of patients. You can demonstrate whether or not care conformed to best-practice guidelines and even decide whether one brand of product works better for your patient population than another brand. That’s amazing if you consider how few of us even thought about these things 10 years ago. We relied on trial and error or personal preference to make decisions; we had no real idea if there was a better method to get great results faster.
Today, there’s still a need for outcome data, and it is still important to know whether we are using best practices and whether we are in line with others caring for similar patient populations. Entry of data previously recorded in medical records is still a time-consuming task, and data entry errors can impact the validity of the reports we obtain. It costs time and money to provide for someone to enter data from a paper record, and sometimes data entry is delayed when other patient care concerns are more pressing. Technology to the rescue again!
At some point we determined that if a computer could handle data analysis from a record, it should be able to extract that data directly from a record. Those original outcome and benchmarking programs were expanded so that care providers could enter the necessary data for reporting directly into patient records, eliminating the need for separate documentation and data entry functions. In addition, we could better decipher what was written in those chart forms. Since we were charting the information anyway, we expanded the amount of data we could manage—and our ability to get reports that provided clinical, operational and reimbursement information grew exponentially.
Those of us who have participated in the information explosion in health care over the past 10 years know that it’s just a matter of time until we give up our pens and paper, if we haven’t already. But for our patients’ sake and our own improvement efforts, we’ll need more and different reports that slice and dice data in new ways. We can expect enhanced decision-support capabilities in electronic record software to help us analyze our assessment data faster and choose appropriate interventions more quickly, and we’ll need more and faster access to all the new information that affects our practice daily.
For a moment, imagine a future in which you don’t even need to run reports to get all the information you need to do your job and to plan and evaluate patient outcomes. It isn’t all that far off—just around the corner, in fact. Much as your car dashboard can tell you exactly what’s going on with your vehicle, how fast you are traveling and how far you’ve gone, computer software can automatically run your important reports and display your very own work dashboard with outcomes, schedules and all sorts of other useful information. Using a secure link on the Internet, you can get that information wherever you are, whenever you want, even on many hand-held devices. Even better, your work dashboard can be different from those of other care providers with whom you work. You can have your own personal data assistant.
Today, with government itself advocating for electronic patient medical records and events like Hurricane Katrina demonstrating the importance of a virtual health record not affected by natural disasters, health care is making the move to full electronic medical records. Many hospitals are implementing electronic records that meet legal and regulatory requirements and limit duplicate charting as they streamline documentation. More vendors of electronic documentation software are addressing the needs of specialty service providers such as wound care specialists. There are programs that let you capture important patient information wherever you are and then drop that into the main patient record whenever it is convenient for you to connect to it.
Change is inevitable; you can take an active part in decisions that will affect how you practice rather than be a victim of change. With this attitude, you’ll carefully review the features of electronic documentation software to be sure that it meets your and your patients’ needs and contributes to the advancement of the practice of wound management. You’ll look for features that are flexible enough to work well in your sites of service and for each type of care provider. You’ll expect that the choice of software and equipment will enhance your workflow and patient throughput, not hinder it, and you’ll expect that what you enter will not only improve your patient outcomes but also help you manage your practice better as you are asked to do more with less. And you’ll expect that whatever you use is as amenable to change as you’ve had to be. Yes, “we’ve come a long way since we last shook hands [but we’ve] still got a long way to go.”
Reference
McGarrigle, K. Come a long way. Recorded by Loudon Wainwright III. On Attempted Mustache (record). New York: Columbia, 1973.
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 Services 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 the Joint Commission and a faculty member of the University of Phoenix in its Master of Healthcare Administration Online Program.